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Chronic Care Management Program (CCM)

Chronic Care Management Program (CCM)

Medicare initiative effective January 1, 2015

CPT 99490: Chronic care management services, 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;

  • comprehensive care plan established, implemented, revised, or monitored;

  • at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month.

Summary of Requirements

  1. Secure the eligible patient’s written consent.

    1. The patient must acknowledge in writing that the provider has explained the following:

      1. the nature of CCM

      2. how CCM may be accessed

      3. that only one provider at a time can furnish CCM for the patient

      4. the patient’s health information will be shared with other providers for care coordination purposes

      5. the patient may stop CCM at any time by revoking consent, effective at the end of that calendar month

      6. the patient will be responsible for any co-payment or deductible

    2. The signed consent form must be recorded in the patient’s medical record.

  2. Have five specific capabilities needed to perform CCM.

    1. Use a certified EHR for specified purposes

      1. providers must have structured recording of demographics, problems, medications, and medication allergies

      2. providers must create summary of care electronically

      3. EHR documentation must include the following in the patient’s medical record:


1. For 2015, an EHR that satisfies either 2011 or 2014 edition of the certification criteria for the EHR Incentive Programs.

2. All consistent with 45 CFR 170.314(a)(3)-(7)
3. Consistent with 45 CFR 170.314(e)(2). Fax is not acceptable
        1. patient consent

        2. provision of care plan to patient

        3. care coordination correspondence

             b. Maintain an electronic care plan
      1. electronic care plans typically include the following:

        1. problem list; expected outcome and prognosis; measurable treatment goals

        2. symptom management and planned interventions

        3. community/social services to be assessed

        4. plan for care coordination with other providers

        5. medication management

        6. responsible individual for each intervention

        7. requirements for periodic review/revision

      2. care plan must be electronically available on a 24/7 basis to all care team members furnishing CCM services billed by the provider

      3. provider “must electronically share care plan information as appropriate with other providers” caring for the patient

      4. provider must make available a paper or electronic copy of the care plan to the patient

c. Ensure patient access to care, provider must:
      1. provide a means for the patient to access care team members on a 24/7 basis to address acute/urgent needs in a timely manner

      2. ensure the patient is able to get successive routine appointments with a designated practitioner or care team member

      3. provide enhanced opportunities for patient-provider (or caregiver-provider) communication by telephone and asynchronous consultation methods

            d. Facilitate transitions of care, provider must have the ability to:
      1. follow-up with the patient after an ER visit

      2. provide post-discharge transitional care management (TCM) services as necessary

      3. coordinate referrals to other clinicians

      4. share information electronically with other clinicians as appropriate

            e. Coordinate care
      1. providers must document communication with patient’s home and community-based clinicians in the EHR

3. Provide 20+ minutes of non-face-to-face care management services per calendar month.
            a. Most non-face-to-face care management services include at least:
      1. performing medication reconciliation and overseeing the patient’s self-management of medications

      2. ensuring receipt of all recommended preventive services

      3. monitoring the patient’s condition (physical, mental, social)

            b. Non-face-to-face care management services may be performed by licensed clinical staff, in this context, includes APRNs, PAs, RNs, LSCSWs,             LPNs, and what CMS refers to as “medical technical assistants” (CNAs and certified medical assistants).

4. Preparation for CCM is not part of the reimbursable service, but may be billed separately as an E&M service.

5. e.g., secure messaging via internet
6. The provider cannot bill for TCM and CCM during the same month. 
            c. General supervision of staff providing non-face-to-face care management services is all that CMS requires
            d. CMS advises providers document at least the following the the patient’s medical record
      1. date and amount of time spending providing non-face-to-face services (preferably start/stop time)

      2. clinical staff furnishing services (with credentials)

      3. brief description of services

            e. Time spent providing services on different days or by different clinical staff members in the same month may be aggregated to total 20                         minutes.


7. Physician or other practitioner available by telephone to provider assistance as required

8. Time of less than 20 minutes during a calendar month cannot be rounded up to meet this requirement; nor may time be carried over from a prior month.

Key Facts

  • CCM pays about $40 per patient per month.

  • There may be some patient responsibility.

  • Medicare Advantage plans will have to cover CCM.

  • Only physicians, advanced NPs, PAs, clinical nurse specialists, and certified nurse midwives can bill Medicare for CCM.

  • You cannot bill for transitional care management, home healthcare supervision, hospice care supervision, and certain end-stage renal disease services in the month you billed CCM.

  • CCM is not recognized as an RHC service.

  • Providers can contract with a third-party to provide non-face-to-face care management services.


CCM Written Consent Example

The Nature of CCM

Chronic Care Management allows physicians to be reimbursed for managing a patient’s chronic conditions through non-face-to-face communication (at least 20 minutes of care per month) in 30-day increments.

How CCM May be Accessed

This care will be provided through telephone or electronic secure messaging. The physician will be performing medication reconciliation, overseeing the patient’s self-management of medications, ensuring receipt of all recommended preventive services, monitoring the patient’s condition. Physicians may allow non-physician medical staff to administer care during the 30-day CCM period.


1. I understand the nature of CCM, as explained above.

2. I understand how CCM may be accessed, as explained above.

3. I understand that only one practitioner can provide and be paid for these services during a 30-day period.

4. I understand I (the patient) can terminate the agreement verbally or in writing at any time.

5. I understand that my protected health information will be shared with other providers for care coordination purposes.

6. I understand that Medicare co-insurance payments apply and that I may be billed at least $8 per month for each 30-day period that your practice bills for the service.


Print Patient’s First and Last Name

____________________________________________________ _____________________

Patient’s Signature Today’s Date