CCM 101

CCM 101


Chronic Care Management was introduced in 2015 as CMS began to strongly urge providers to get aligned with the payer (CMS) in managing health rather than just treating sickness.  This initiative has significantly pushed forward with the introduction of over 20 more programs all aimed at creating comprehensive care management practices out of Primary Care.  This program is one of the first steps in learning how to effectively manage complex patients, and still be reimbursed through somewhat traditional means. While it is not a 1-to-1 service like a traditional E/M code, the CCM CPT code is still a single billable code; but unlike a E/M code, it is for time spent managing and coordinating services for chronically ill complex patients that in the past was too burdensome and time consuming to perform without some form of reimbursement.  While CCM will not be a golden goose for any practice, it is a great way to be reimbursed to develop your team, sharpen their skills, expand your capabilities, and march towards the larger mission of Comprehensive Care Management that CMS desires.

CCM 101

Chronic Care Management (CCM) is defined as the non-face-to-face services provided to Medicare beneficiaries who have two or more significant chronic conditions. In addition to office visits and other face-to face encounters, which must be billed separately, these services include communication with the patient and other treating health professionals for care coordination (both electronically and by phone), medication management, and providing accessibility 24 hours a day to patients and other treating physicians or clinical staff.

The creation and revision of electronic care plans is also a key component of CCM. The designated CCM clinician (MD, PA, NP) must establish, implement, revise, or monitor and manage an electronic care plan that addresses the physical, mental, cognitive, psychosocial, functional, and environmental needs of the patient as well as maintain an inventory of resources and supports that the patient needs.

Only one clinician can bill for CCM services for a particular patient. Therefore, it may be necessary to coordinate with sub-specialists who may be providing a significant amount of care and treatment for one or more of the patient’s conditions. Since many patients have multiple physicians, it is important for patients to understand that only one physician will be able to bill for CCM services. The CCM code is generally intended for use by the clinician who is providing the majority of the coordination services, which is typically the primary care physician. However, certain specialists may be able to provide the services needed to qualify to bill the CCM code.



The CCM code can only be billed by a physician, advanced practice registered nurse, clinical nurse specialist, or physician assistant.


Eligible patients must have “2 chronic continuous or episodic health conditions that are expected to last at least 12 months, or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline.” The list is not exclusive but has been identified as:

  • Asthma
  • COPD
  • CHF
  • HTN
  • CAD
  • A-Fib
  • High cholesterol
  • Cancer
  • Diabetes
  • Osteoporosis
  • Arthritis
  • Dementia / Alzheimer’s
  • Parkinson’s
  • Post CVA
  • Depression


This is an electronic summary of the physical, mental, cognitive, psychosocial, functional, and environmental assessments, including: recommended preventive care services; medication reconciliation with review of adherence and potential interactions oversight of patient self-management of medications; an inventory of clinicians, resources, and supports specific to the patient, including how the services of agencies or specialists unconnected to the designated physician’s practice will be coordinated; and the assurance of care appropriate for the patient’s choices and values. This will also include a plan that covers issues beyond the traditional medical issues that the physician would routinely care for, collaborative care management, and an interactive care plan that will always be up to date and encompass a holistic patient care management perspective.


Licensed clinical staff members (including APRN, PA, RN, LSCSW, LPN, clinical pharmacists, and “medical technical assistants” or CMAs) who are directly employed by the clinician (or the clinician’s practice) or a contracted third party and whose CCM services are generally supervised by the clinician, whether provided during or after hours. Thus the “incident to” rules do not necessarily require that the clinician be on the premises providing direct supervision.


To count the time towards the required 20 minutes of non-face-to-face care, the care must be “contact initiated.” This could be patient-doctor, patient-nurse, doctor-doctor, pharmacy-doctor, lab-doctor, or other contact regarding or by the patient via phone or electronic communication. General planning time or care coordination does not count unless it is initiated based on a contact and/or results in a patient or patient-related contact. For example, if the pharmacist calls the physician’s office because the patient reported a rash, this time counts. If the physician’s office spends time running reports of all participants who are due for a flu shot or an A1C check, the time does not count. When a clinician calls and speaks to the patient and then coordinates care, the time counts. In-person visits, including group visits, do not count toward the CCM code.


Essentially, the originating data set and main data set housed on patients should still originate in the Certified EMR. Other programs or platforms can assist in the CCM delivery, but the patient should still maintain a base record in the Certified EMR.

Patient Consent

A verbal recording of consent is acceptable, but written consent is optimal.  Patient opt out should be stored in writing as well.  An initiating E/M visit or AWV should be completed F2F within the prior 6 months, but this is not mandatory. However, hearing the decision to enroll from the PCP will greatly enhance patient adoption and participation.

Billing Requirements

  • CPT 99490 – original CCM code – allows eligible practitioners and suppliers to bill for at least 20 minutes of non-face-to-face clinical staff time each month to coordinate care for patients who have two or more chronic conditions.
    • 20 Minutes – $42 average reimbursement
  • CPT 99487 – for complex CCM that requires substantial revision of a care plan, moderate or high complexity medical decision making, and 60 minutes of clinical staff time.
    • 60 Minutes – $93 average reimbursement
  • CPT 99489 – is a Complex CCM add-on code for each additional 30 minutes of clinical          staff time.
    • 30 Minutes – $47 average reimbursement
  • HCPCS G0506 –  is an add-on code to the CCM initiating visit for providing a comprehensive assessment and care planning to patients.
    • One-time – $63 average reimbursement
  • POS on the claim should be the physician office or where the care is routinely provided on E/M visits
  • DOS can be any day that the minimum criteria minute threshold was met, but often is done at once at the end of the month
  • ICD on the claim should include the chronic conditions
  • Only ONE NPI is allowed to bill for this at a time
  • The CCM codes CANNOT be billed if the criteria is not met, the patient opted out, OR the following codes were already billed that calendar month (most of these codes reimburse more than CCM so they should take precedence)
    • Transition Care Management (TCM) – CPT 99495 and 99496
    • Home Healthcare Supervision – HCPCS G0181
    • Hospice Care Supervision – HCPCS G9182
    • Certain ESRD services – CPT 90951-90970
  • If other E&M or procedural services are provided, those services will be billed as appropriate. That time can NOT be counted toward the 20 minutes for CCM. If time — such as from a phone call — leads to an office visit resulting in an E&M charge, that time would be included in the billed office visit, NOT the CCM time.
  • Copayments (coinsurance and deductibles) DO apply.
  • Specific fee schedule info can be found here

How to do CCM


    1. Search through your EMR for patients with 2 or more chronic conditions
    2. Identify patients who would be a good fit for this program
      1. Think about engagement, participation, attitude towards technology
    3. Consider an outreach campaign (email, phone, flyer) to explain the new services being offered

Educate the patients about the importance of the program, the cost savings to CMS, and how it helps your practice really take care of all of the complex needs. Explain how they can opt out, and how they can only allow one physician at a time to be performing these services.  Explain that your program uses YOUR staff, and that you are not outsourcing this to remote call centers.  Explain to the patient that they will have a login and an account for this program beyond their portal. Explain that their main point of contact will be a designated team member who will be the main care coordinator.  Review patient financial responsibility.  Review the agreement form, and obtain consent.  Document this in the EMR and store the form in the patient record.


Perform a comprehensive assessment that shows the patient just how holistic this program is.  Identify issues, make recommendations, and create a care action plan to ensure accountability in meeting the needs of the patient.

The key to success is patient buy-in.  The patient will need to be available, engage in the platform, engage with your team, and look at the CCM team as the head chef and head conductor and keep them abreast of all conditions, tests, medications, changes, and outcomes performed by other providers.  Create the sense of having an individualized care manager.

Go over basic login to access the care plan, input vitals, input symptom reports, communicate with their entire care community, and upload changes to conditions.

Perform, Document, And Bill

Perform the care management and care coordination services that likely you have bee performing all along. But now, you will document these services, and then have an opportunity to reimburse your practice for the time spent managing the complex conditions.  Track emails, system communication, phone calls, referral coordination, prescription management, education, and more.

At the end of the month, determine if CCM or CCCM billing is appropriate.  Affirm the billing codes, and send the claims for reimbursement.

Enroll new patients as they become interested and eligible, and continue to serve the patients already on service.  Build your team from within and evolve towards a true comprehensive care management team who can help keep costs to CMS low, outcomes high, and patient satisfaction optimal.  This program meets many CPIA, HEDIS, and MACRA initiatives.


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