Chronic Care Management: Enhancing Patient Outcomes

Chronic Care Management (CCM) is transforming healthcare for patients with long-term conditions. It’s more than just check-ins—it improves patient outcomes, boosts Medicare reimbursements, and streamlines care coordination. Since 2015, Medicare and Medicaid Services have recognized CCM, making it an essential tool for providers. But how does it work? What are the billing criteria? And how can providers maximize its benefits while staying compliant?

KEY TAKEAWAYS

CCM is a Medicare-recognized service for managing patients with two or more chronic conditions.
Only one provider per month can bill for CCM, so communication is crucial.
Accurate time tracking (minimum 20 minutes) is essential for proper billing.
Telehealth greatly enhances CCM but rules may change after the PHE.
Implementing CCM increases revenue, improves patient outcomes, and demands strict compliance.

What Is Chronic Care Management (CCM) and Why Does It Matter?

At its core, chronic care management is designed to help patients with two or more chronic conditions manage their health more effectively. These are conditions expected to last at least 12 months or longer (or until the patient’s death) and that put them at risk of serious complications.

The goal?
Keep patients healthier for longer, prevent unnecessary hospitalizations, and provide ongoing, proactive care rather than just reactive treatment.

The best part for providers? CCM services are reimbursable. Medicare recognizes the value of non-face-to-face care and compensates physicians, nurse practitioners, and clinical staff for the time spent managing these patients outside of their normal in-person visits.

How Medicare and Medicaid Support Chronic Care Management

Medicare offers specific CPT codes that allow healthcare providers to bill for chronic care management services. This reimbursement acknowledges the time and effort required to:

Monitor a patient’s condition
Coordinate with specialists
Review medical records
Follow up on lab results and medications
Conduct non-face-to-face communication through phone, email, or patient portals

However, only one provider per month can bill for CCM services for a single patient. So, if a primary care physician and a cardiologist both provide care for the same patient, only one of them can submit a claim.

This lack of a streamlined billing system can sometimes result in claim denials, forcing providers to absorb the costs if they unknowingly bill for a patient already covered under another provider’s CCM plan that month.

How Patients Qualify for Chronic Care Management Benefits

To qualify for chronic care management benefits, patients must meet specific criteria:

They must have at least two chronic conditions
These conditions must be expected to last 12 months or longer
The conditions must put them at risk of worsening, hospitalization, or functional decline

Additionally, patients must give consent for CCM services, either verbally or in writing, and it must be documented in their medical records.

Patients also need to understand that they can cancel their CCM enrollment at any time without any penalty, and their overall medical care won’t be affected.

How Chronic Care Management Is Provided

One of the biggest chronic care management benefits is that it doesn’t always require in-person visits. Many of the services provided under CCM are non-face-to-face and can be conducted via:

Telephone calls
Secure emails
Patient portals
Administrative tasks like coordinating referrals

Each month, providers track their time spent managing the patient’s care, ensuring they meet the minimum 20-minute requirement to bill Medicare.

But here’s the catch—once a claim is submitted for that month, it cannot be modified. So if a provider submits a CCM claim on the 20th day of the month but ends up spending additional time with the patient later in the month, they cannot add that extra time to the claim.

Can You Bill CCM and TCM in the Same Month?

One important billing rule: CCM and Transition Care Management (TCM) services cannot be billed in the same month.

For example, if a patient is hospitalized and then discharged, their doctor may bill for TCM services during the transition period. However, if TCM is billed for that month, CCM cannot be billed as well. Providers must decide which service is most appropriate and financially viable.

CCM Billing Codes: What Providers Need to Know

One of the biggest chronic care management benefits for providers is that it’s billable through Medicare and other insurance payers. But to get properly reimbursed, providers must understand which CPT codes apply to the services they offer.

The 4 Key CCM Billing Codes

CPT Code	Description	Who Can Bill It?	Time Requirement
99490	Standard CCM services (non-face-to-face)	Clinical staff	20+ minutes per month
99491	CCM services personally provided by a physician or NP	Physician, NP, or PA	30+ minutes per month
99487	Complex CCM services (increased complexity of care)	Clinical staff	60+ minutes per month
99489	Additional 30 minutes of complex CCM	Clinical staff	Billed in addition to 99487

Who Can Bill for CCM?

Not all CCM services need to be provided by a doctor. In fact, many can be billed by clinical staff (nurses, medical assistants, or care coordinators), which makes it easier for practices to implement CCM without overburdening physicians. However, codes like 99491 must be personally performed by a physician, nurse practitioner, or physician assistant.

The key takeaway? Choose the correct CPT code based on time spent and provider level.

Avoiding Common CCM Billing Mistakes

Even though chronic care management benefits both patients and providers, billing for it isn’t always straightforward. There are strict guidelines to follow, and one mistake could lead to claim denials or compliance issues.

Only One Provider Can Bill for CCM Each Month

This is a big one! If a primary care physician (PCP) and a specialist (e.g., cardiologist) both provide CCM services to the same patient, only one can bill for it that month. If you try to bill for a patient who already has an active CCM claim from another provider, your claim will get denied—and unfortunately, you’ll have to eat that cost.

Solution? Have clear communication with patients and coordinate with other providers when necessary.

Tracking Time Accurately Is Critical

Since CCM billing is based on time, you must meticulously track every minute spent coordinating a patient’s care. This includes:

Phone calls to the patient or their caregivers
Reviewing medical records
Coordinating referrals and specialist visits
Monitoring lab results and adjusting treatment plans

Miss tracking even a few minutes? You might not meet the billing threshold.

Submitting Claims Too Early Can Cost You

Let’s say you meet the 20-minute requirement on the 15th of the month. Should you submit the CCM claim immediately? Not always.

If you end up spending more time on the patient later in the month, you won’t be able to adjust the claim after it’s submitted. That means you could be leaving money on the table.

Best practice? Many practices wait until the end of the month to submit CCM claims to ensure they capture all billable time.

How Telehealth Has Transformed Chronic Care Management

One of the biggest chronic care management benefits today is how telehealth has made it easier than ever for providers to manage patients remotely.

During the Public Health Emergency (PHE), Medicare loosened some of the face-to-face visit requirements for CCM. This made it easier for providers to conduct CCM check-ins via telehealth, reducing the burden on both patients and healthcare professionals.

Current Telehealth Flexibilities for CCM

The initial CCM visit (which must be face-to-face) can now be done via telehealth
Follow-ups can be conducted via phone calls, secure messaging, or video calls
Patients can receive CCM services without physically coming into the office

However, with the PHE expected to expire, some of these flexibilities might change. Providers need to stay updated on Medicare’s rules and prepare for a shift back to stricter in-person requirements.

How to Implement CCM Successfully in Your Practice

If you’re a healthcare provider looking to offer chronic care management benefits to your patients, you need a structured workflow to stay compliant and maximize reimbursements.

Steps to Implement CCM Effectively

Identify Eligible Patients
- Patients must have at least two chronic conditions
- Ensure they understand CCM services and potential out-of-pocket costs
Obtain & Document Patient Consent
- Consent can be verbal or written, but must be documented in their chart
- Patients should know they can cancel at any time
Set Up Time Tracking Systems
- Use EHR systems or dedicated CCM tracking tools
- Make sure every minute is logged properly for billing
Assign Responsibilities
- Which staff members will handle CCM tasks?
- Will you use clinical staff for standard CCM (99490) or physicians for complex CCM (99491)?
Develop a Billing Strategy
- Decide when claims will be submitted (e.g., end of the month)
- Keep up with Medicare updates to avoid compliance issues

Chronic Care Management Benefits: FAQ

Still have questions about chronic care management benefits? You’re not alone! Here’s a breakdown of the most frequently asked questions about CCM, from eligibility requirements to billing and compliance.

What Is Chronic Care Management (CCM)?

Chronic care management is a Medicare-recognized service that allows healthcare providers to bill for non-face-to-face care of patients with two or more chronic conditions. The goal is to improve patient outcomes by offering ongoing support, care coordination, and proactive monitoring.

Who Qualifies for Chronic Care Management Benefits?

To be eligible for CCM services, a patient must:

Have at least two chronic conditions
Expect to have these conditions for at least 12 months or until death
Be at risk of functional decline, hospitalization, or serious health complications
Provide consent (verbal or written) for CCM services

If these conditions are met, Medicare and many commercial insurances will cover CCM services.

What Conditions Count as “Chronic” for CCM?

There is no official list of qualifying conditions, but common chronic diseases covered under CCM include:

Diabetes
Hypertension (high blood pressure)
Heart disease
Chronic kidney disease (CKD)
Asthma or COPD (chronic obstructive pulmonary disease)
Arthritis
Depression or anxiety disorders
Dementia or Alzheimer’s disease

If a condition requires long-term management and could worsen without consistent care, it likely qualifies for CCM.

What Services Are Included in CCM?

CCM covers non-face-to-face services such as:

Phone calls and emails between providers and patients
Medication management and adjustments
Care coordination between specialists, PCPs, and other providers
Referrals and follow-ups
Remote monitoring of symptoms and lab results
Patient education and support

These services are tracked monthly, and providers must spend at least 20 minutes managing a patient’s care to bill Medicare.

What CPT Codes Are Used for CCM Billing?

CPT Code	Service Description	Who Can Bill?	Time Requirement
99490	Standard CCM (basic care coordination)	Clinical staff	20+ minutes per month
99491	CCM personally provided by a physician or NP	Physician, NP, or PA	30+ minutes per month
99487	Complex CCM (more intensive care)	Clinical staff	60+ minutes per month
99489	Additional 30 minutes of complex CCM	Clinical staff	Billed in addition to 99487

Can More Than One Provider Bill for CCM for the Same Patient?

No. Only one provider per month can bill for chronic care management benefits for a single patient.

For example, if a primary care physician (PCP) and a cardiologist both treat a patient, only one of them can bill for CCM services that month. If multiple providers submit claims, Medicare will reject the duplicate submission.

Can CCM Be Billed in the Same Month as TCM (Transitional Care Management)?

No. CCM and Transitional Care Management (TCM) services cannot be billed together in the same month.

If a patient is discharged from the hospital and their provider bills for TCM services, CCM cannot be billed until the next month. Providers must choose the service that is most appropriate for billing.

Does CCM Require a Face-to-Face Visit?

Yes, but only initially. The first CCM visit must be conducted in person (or via telehealth during the Public Health Emergency).
After the first visit, all CCM services can be non-face-to-face, meaning follow-ups can be done via phone calls, emails, or patient portals.

How Does Telehealth Impact Chronic Care Management?

During the Public Health Emergency (PHE), Medicare relaxed face-to-face visit requirements for CCM, allowing:

Initial CCM visits via telehealth
Follow-ups via phone or secure messaging
Easier access to remote care coordination

However, these telehealth flexibilities may change once the PHE ends, so providers should stay updated on Medicare policies.

Does CCM Have a Cost for Patients?

Yes, there can be out-of-pocket costs.

Medicare Part B patients are responsible for 20% co-insurance after meeting their deductible.
Some Medicare Advantage and commercial insurance plans cover CCM with no out-of-pocket costs.
Patients must be informed of potential charges before they consent to CCM services.

How Can Providers Track CCM Time Accurately?

Since CCM is time-based billing, providers must:

Log every minute spent coordinating patient care
Use EHR systems or CCM tracking software
Submit claims at the end of the month to capture all billable time

Is Chronic Care Management Worth It for Providers?

Yes! Offering CCM has multiple benefits:

Improves patient health outcomes by providing consistent, proactive care
Increases practice revenue through Medicare reimbursements
Reduces hospitalizations and complications for chronic patients
Allows clinical staff to handle many CCM tasks, freeing up physician time

While CCM does require strict documentation and compliance, many providers find it financially and clinically valuable.

How Can I Start Implementing CCM in My Practice?

If you’re a healthcare provider looking to offer chronic care management benefits, here’s how to start:

Identify eligible patients (2+ chronic conditions, Medicare/insurance coverage)
Obtain patient consent (verbal or written)
Set up a time-tracking system (EHR or CCM software)
Train staff on CCM workflows and compliance
Decide on billing strategy (when to submit claims, who will bill)
Stay updated on Medicare policies to avoid billing errors

Final Thoughts on Chronic Care Management Benefits

The chronic care management benefits for both patients and providers are undeniable. Patients get better, more proactive care, while providers get reimbursed for time spent coordinating complex cases.

However, successful CCM implementation requires a strong understanding of billing codes, compliance rules, and telehealth policies. By tracking time accurately, choosing the right CPT codes, and staying updated on Medicare guidelines, you can maximize reimbursements while improving patient outcomes.