Chronic Care Management (CCM) continues to be a powerful tool for providers focused on value-based care and improved patient outcomes. Whether you’re just getting started or looking to optimize your existing program, there are always questions about billing, eligibility, staffing, and compliance.
At TimeDoc Health, we’ve helped hundreds of practices and health centers launch and scale successful CCM programs. Here’s our comprehensive chronic care management guide to the most common questions we hear—from clinical workflows to billing to technology implementation.
1. Whose time counts toward the 20-minute CCM requirement?
Time spent by physicians, non-physician practitioners (NPs, PAs, CNMs, CNSs), and clinical staff working under general supervision of the billing provider counts. This typically includes:
- Registered Nurses (RNs)
- Licensed Practical Nurses (LPNs)
- Certified Medical Assistants (CMAs)
- Licensed Clinical Social Workers (LCSWs)
- Certified Nurse Assistants (CNAs)
Non-clinical staff time does not count toward the 20-minute requirement. TimeDoc Health can help clarify which roles are eligible in your state.
2. What activities count toward those 20 minutes?
Qualifying non-face-to-face activities include:
- Patient or caregiver communications (calls, emails, secure messaging)
- Reviewing labs, imaging, and consult reports
- Creating or updating care plans
- Chart documentation
- Medication reconciliation and refill coordination
- Closing referral loops
- Communicating with community or home-based providers
- Remote monitoring reviews
- Post-discharge follow-up
3. Can I be reimbursed for more than 20 minutes of care?
Yes. In addition to CPT 99490 (20 minutes), CMS has introduced codes for more complex care:
- 99487 – First 60 minutes of complex CCM
- 99489 – Each additional 30 minutes
TimeDoc Health tracks this automatically, so you never miss billable time.
4. What insurance plans reimburse for CCM?
- Medicare and most Medicare Advantage plans reimburse for CCM.
- Commercial plans are increasingly supporting it but may vary.
- Fee-for-service contracts qualify; capitated contracts typically do not.
5. Is there a specific list of chronic conditions?
No official list. CMS allows providers to use clinical judgment for patients with two or more chronic conditions expected to last 12 months or longer that place the patient at risk of death, acute exacerbation, or functional decline.
6. Are patients in facilities eligible?
Generally, no. CMS excludes patients in facilities (e.g., SNFs, hospitals) already receiving Medicare facility payments. However, patients in assisted living may qualify depending on billing status.
7. Are patients responsible for a copay?
Yes. For 99490, patients are responsible for 20% (around $8/month). Most Medigap or Medicare Advantage plans cover this. TimeDoc Health can help develop a communication plan to explain CCM value to patients.
8. How do we explain the charge to patients?
Here are some chronic care management guide talking points:
- CCM helps prevent hospitalizations and keeps patients healthier at home.
- Medicare is now reimbursing for the time and care your team has always provided.
- CCM is part of a national shift to value-based care that rewards better outcomes.
9. Can a patient be enrolled with more than one provider?
No. Only one provider can bill CCM per patient per month. Patients should be asked if they’ve enrolled elsewhere. Medicare pays the claim based on who bills first.
10. Do services need to be provided every month?
Not necessarily. If no services are provided in a given month, no claim should be submitted, but the patient’s consent remains in effect until revoked.
11. When is CCM not billable?
CCM cannot be billed in the same month as:
- Transitional Care Management (99495, 99496)
- Home health or hospice supervision (G0181, G0182)
- Certain ESRD codes (90951–90970)
TimeDoc Health’s system automatically flags these scenarios to avoid billing conflicts.
12. How does my biller know who’s billable?
TimeDoc Health tracks time per patient and generates a monthly billing report showing which patients met the 20-minute threshold. This report integrates with your internal or third-party billing workflow.
13. How can we collect patient copays?
Common strategies include:
- Credit card on file
- In-person collection at the next visit
- Mail or portal-based billing options
TimeDoc can help you implement best practices that fit your patient population.
14. What documentation is needed for audit protection?
- Track and document at least 20 minutes of qualifying time
- Maintain a detailed, up-to-date care plan
- Log all communications, assessments, and interventions
TimeDoc integrates with your EHR and maintains a clear audit trail for every enrolled patient.
15. Is TimeDoc Health HIPAA-compliant?
Absolutely. Our platform is hosted on HIPAA and HITECH-compliant infrastructure and undergoes regular security audits. Every team member is trained in privacy and compliance best practices.
16. How long does implementation take?
We move at your pace. Most practices are up and running in a matter of weeks. We work directly with your IT team and provide virtual or on-site training based on your needs.
17. Are FQHCs and RHCs eligible for CCM?
Yes. Since 2016, FQHCs and RHCs have been eligible to bill for CCM under code G0511. Requirements for consent, services, and documentation are the same as for general practices.
18. How does CCM differ for FQHCs and RHCs?
- Clinical staff must initially operate under direct supervision
- In 2017, CMS updated rules to allow general supervision
- CCM can be outsourced to vendors like TimeDoc Health
- Reimbursement is bundled under G0511 rather than individual CPT codes
- The payment rate for G0511 is nationally set and not geographically adjusted
TimeDoc Health has extensive experience supporting FQHCs and RHCs with compliant, high-performing CCM programs.
Still Have Questions? Let’s Talk
Whether you’re a large health system or a small clinic, TimeDoc Health’s Chronic Care Management Guide can help you launch or expand your CCM program with ease and confidence. From implementation to compliance, we’re with you every step of the way.