Chronic Care Management (CCM)
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Chronic Care Management (CCM) refers to the coordination of care provided outside of regular office visits for patients with two or more chronic conditions. These conditions must be expected to last at least 12 months (or until the patient’s death) and pose a significant risk of death, acute exacerbation, decompensation, or functional decline.
Common examples of chronic conditions
Alzheimer’s disease and dementia
Arthritis
Asthma
Cancer
Heart disease
Diabetes
High blood pressure
COPD (Chronic Obstructive Pulmonary Disease)
Depression
HIV/AIDS
Key Requirements for CCM
Two or more chronic conditions expected to last at least 12 months (or until the death of the patient).
Patient consent (verbal or signed): Patients provided consent through the Enrollment Packet, your Clinical Note provides area for you to verify and confirm consent at the time of the Comprehensive Visit.
Personalized care plan in a certified EHR and a copy provided to patient.
24/7 patient access to a member of the care team for urgent needs. The patient/caregiver will need your contact information.
Enhanced non-face to face communication between patient and care team
Management of care transitions.
Practitioners can bill for Chronic Care Management (CCM) on a calendar-month basis when at least 20 minutes of non-face-to-face clinical staff time, under the direction of a physician or other qualified healthcare professional, is dedicated to care coordination for a Medicare patient with multiple chronic conditions. This time must involve activities focused on managing and coordinating care for eligible patients.
Who can bill CCM Services?
Physicians and certain Non-Physician Practitioners (Physician Assistants, Clinical Nurse Specialists, Nurse Practitioners, and Certified Nurse Midwives)
RHCs and FQHCs, Hospitals, including Critical Access Hospitals
*Only one physician, NPP, RHC or FQHC, and one hospital, can bill for CCM for a patient during a calendar month.
According to CMS guidelines, Chronic Care Management (CCM) time may include contributions from qualified healthcare professionals such as pharmacists, social workers, dietitians, psychologists, and other Non-Physician Practitioners (NPPs). Their work, including care coordination, medication management, patient education, and behavioral health support, can be added to the total CCM time and billed under CPT 99490 for non-complex CCM services. This allows the entire care team’s efforts to be accounted for, ensuring comprehensive and coordinated care for patients.
Activities that can count toward the minimum monthly service time required to bill for CCM
Providing CCM services outside of in-person visits, such as through phone calls or secure emails.
Engaging in care coordination activities that are not typically part of face-to-face encounters.
This can involve reviewing medical records and test results, offering self-management education and support, and coordinating or exchanging health information with other practitioners and healthcare professionals.
Including some face-to-face interactions with the patient or other healthcare professionals.
Additional examples of Non- Face –to Face Coordination of Care Activities Physicians/QHP often engage in:
Review need for, or follow-up on, pending diagnostic tests and treatments, for example the Medication Management results from GTI
Responding to Alerts from 1Bios system, documenting a Clinical Note in BlueStep
Interacting with other health care professionals who will assume or reassume care of the patient’s system-specific problems
Assist in scheduling required follow-up with community providers and services, CMS prefers to see documentation of assisting the patient/caregivers versus only instructions to do the task.
Provide education to the patient, family, guardian, and/or caregiver
Establish or re-establish referrals and arrange for needed community resources
Initiating Visit
Before CCM services can start, CMS require an initiating visit for new patients or patients who the billing practitioner hasn’t seen within the previous 1 year. The clinician must initiate a Comprehensive Visit, following the approved E/M visit guidelines. In the virtual clinician office, CPT Code 99215 meets this requirement.
The initiating visit can happen during a comprehensive face-to-face evaluation and management (E/M) visit, annual wellness visit (AWV), or initial preventive physical exam (IPPE).
If the practitioner doesn’t discuss CCM during an E/M visit, AWV, or IPPE, it can’t count as the initiating visit. A face-to-face initiating visit isn’t part of CCM and can be separately billed.
Practitioners who personally provide extensive assessment and care planning outside the usual effort described by the initiating visit and CCM codes may also bill HCPCS code G0506 once, as part of an initiating visit.
Should the patient admit to the hospital they would be able to return to the program and participate in Transitional Care Management(TCM) services.
Coordination of Care Documentation
Coordination of Care Documentation
CCM CPT Code Descriptions
CCM CPT Code Descriptions
99490
Non-complex CCM is a 20 minute timed service provided by clinical staff to coordinate care across providers and support patient accountability.
This work is completed by your 1Bios Clinical Care Staff.
99439
Each additional 20 minutes of clinical staff time spent providing non-complex CCM directed by a physician or other qualified health care professional (billed in conjunction with CPT 99490)
99487
Complex CCM is a 60 minute timed service provided by clinical staff to substantially revise or establish comprehensive care plan that involves moderate to high complexity medical decision making.
99489
Each additional 30 minutes of clinical staff time spent providing complex CCM directed by a physician or other qualitied health care professional (billed in conjunction with CPT 99487; cannot be billed with CPT code 99490.
99491
CCM services provided personally by a physician or other qualified health care professional for at least 30 minutes and cannot be billed with CPT code 99490. In your program, the physician will provide and bill for this CCM service during the first month of care, after any initial visit has been completed.
99437
99437 Each additional 30 minutes of CCM services provided personally by a physician or other qualified health care professional (billed in conjunction with 99491).
Quick Review
The patient will begin the program with the first virtual care visit and as needed.
After the first virtual care visit the physician will provide coordination of care activities in between visits to prepare the patient to receive care and services you will delegate to your Clinical Staff at the beginning of the following month.
The physician/QHP will document tasks/time in the Clinical Notes section of the patient EHR, time is cumulative and billed at the end of the month.
At the end of the first month, the physician will be able bill CCM CPT codes 99491 (30 min) and 99437 (additional 30 min) depending on the total time spent with providing CCM Coordination of Care Tasks.
Under CMS guidelines, CPT codes 99489, 99491, and 99490 cannot be billed together for the same patient within the same calendar month, as each represents distinct Chronic Care Management (CCM) services. To avoid duplication, only one code may be billed per month. Practices must select the appropriate code based on the specific services provided and ensure the documentation fully supports the billing choice.
Additionally, if a physician or NP documents extra CCM time, it can be included in the total time billed under CPT 99490, provided the time meets the necessary thresholds and requirements. This approach ensures all care coordination efforts are accurately accounted for and compliant with CMS billing standards.
For more information, refer to the Centers for Medicare & Medicaid Services (CMS) resources.
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