Chronic Care Management

Care Planning for Chronic Care Management CPT Code 99490

The on-going list of chronic illnesses can seem endless and the risk of developing at least one condition is inevitable for many individuals. However, a personalized care plan can be a difference maker for patients in preventing or minimizing the effects of their chronic illnesses. Consequently, a requirement to bill for Medicare’s Chronic Care Management (CCM) CPT code 99490 is building a care plan and sharing it with the patient. Since the role of care planning in chronic disease management is pivotal, we’ve laid out answers to some of the most common questions around CCM care planning:

What is a CCM care plan?

In general, the care plan is a collaborative approach between patient and provider and an integral part of CCM. Specifically defined, a comprehensive CCM care plan is a person-centered blueprint based on a physical, mental, cognitive, psychosocial, functional, and environmental assessment and reassessment that includes an inventory of resources available to the patient. In other words, it is a dynamic playbook of all the relevant information about the patient’s health issues and his or her goals for treatment, particularly focusing on the chronic conditions being managed.

What role does a care plan have in the patient’s health?

The goal of a care plan is to equip patients with the ability to better manage their own health. There are many aspects to self-management, such as medication adherence, maintaining healthy lifestyles, monitoring symptoms, and knowing when to seek medical help that can be confusing for patients. The purpose of a care plan is to engage with patients to create a tailored approach to the individual’s needs based on their conditions and the resources available to them. They effectively map out short and long term goals while proactively identifying obstacles in reaching those goals.

What is Medicare’s requirement for sharing care plans?

Ensuring that patients have access to their care plans is crucial for the success of chronic disease management. Per Medicare requirements, patients must have electronic access to their plan. While Medicare only requires that plans be shared electronically, we know that many of these patients might have technological challenges. These challenges could include limited resources to access their plans electronically or the lack of education on how to use technology to access them. Due to these challenges, TimeDoc Health mails a physical copy of the care plan directly to the patient when he or she enrolls in our client’s CCM program. We believe that when patients have easy access to this plan, their outcomes are much better leading to a higher program retention rate for our clients.

Who should have access to a patient’s care plan?

Aside from the patient, the care plans should be accessible to all providers at the practice and shared with any clinical staff outside of the practice that works with the patient. While it is not a requirement to incorporate care plans into your electronic health record (EHR) system, doing so creates an efficient way for all providers to have access to this document. TimeDoc Health software securely integrates with the most of the common EHRs and through this integration, we are able to push care plan documents so that they can be accessed directly from the patient chart.




Who should create the CCM care plan?

Licensed clinical staff members with oversight from the patient’s physician, in conjunction with the patient, are typically the parties responsible for creating the CCM care plans. Clinical staff can include LPNs, RNs, MA, PAs, NPs, and LCSW.

What should be included on a CCM care plan?

According to Centers for Medicare and Medicaid Services (CMS), a comprehensive care plan for all health issues typically includes, but is not limited to, the following elements:

  • Problem list
  • Expected outcome and prognosis
  • Measurable treatment goals
  • Symptom management
  • Planned interventions and identification of the individuals responsible for each intervention
  • Medication management
  • Community/social services ordered
  • A description of how services of agencies and specialists outside the practice are directed/coordinated
  • Schedule for periodic review and, when applicable, revision of the care plan

Is the care planning process reimbursable?

Yes, since a large portion of the care planning process is a collaborative discussion with the patient, the time spent on care planning can be submitted for reimbursement.

When should care plans be updated?

Successful care plans are an iterative process that continually get updated based on how patients are doing. Any information collected during the routine monthly care call with a patient that reflects changes in a patient’s mental, cognitive, psychosocial, functional, and environmental assessment should get updated in the care plan.

Is there a way to automate the care plan process?

Care planning can be one of the most time-consuming parts of enrolling eligible patients into a chronic care management program. Though tedious, this step is essential to ensure the greatest success for patient outcomes and satisfaction. One of the biggest advantages of working with software vendors who specialize in CCM, like TimeDoc Health, is the ability to automate this process. Our CCM software comes preloaded with care plan templates that were created by physicians using evidence based protocol for the most common chronic conditions. Automating the process cuts down the time consuming, administrative tasks so that providers can spend time working with patients on building effective plans.

Centers for medicare and medicaid services. (2019). Chronic Care Management Services MLN Booklet. Retrieved from
Cochrane library. (2015). Personalised care planning for adults with chronic or long‐term health conditions. Retrieved from