Managing chronic conditions requires more than occasional visits—it demands consistent, proactive, and coordinated care. Chronic Care Management (CCM) programs, supported by CPT billing codes, enable providers to deliver continuous support to patients while generating reimbursable revenue.
But to run a successful CCM program, healthcare organizations need to understand the codes, build strong care plans, and ensure patient access—all while meeting Medicare requirements.
This guide explains the essential CCM CPT codes, the role of care plans in chronic disease management, and how to optimize your program with the right technology and support.
What Is Chronic Care Management (CCM)?
CCM refers to non-face-to-face services provided to Medicare patients with two or more chronic conditions expected to last at least 12 months or until death. These conditions place the patient at risk of significant health decline or death and require structured care planning and monitoring.
Common chronic conditions include:
- Diabetes
- Hypertension
- COPD
- Heart disease
- Asthma
- Arthritis
- Depression
- Alzheimer’s and Dementia
- Cancer
CCM improves patient engagement, reduces hospital visits, and promotes continuity of care—benefiting both patients and providers.
The Role of a CCM Care Plan
The care plan is the foundation of a CCM program and a core requirement for billing.
According to CMS, a CCM care plan must be:
✔ Person-centered and dynamic
✔ Based on physical, cognitive, psychosocial, and environmental assessments
✔ Shared electronically with the patient
Key elements of a compliant CCM care plan:
- Problem list and prognosis
- Measurable treatment goals
- Symptom management
- Interventions and responsible care team members
- Medication management
- Community services
- Coordination across care teams
- Schedule for regular reviews and updates
At TimeDoc Health, we automate the creation of these care plans using pre-built templates based on evidence-based protocols. For patients with tech limitations, we also mail a printed version of the care plan to ensure accessibility and improve engagement.
CPT Codes That Support Chronic Care Management
99490 – Standard CCM
- 20+ minutes/month by clinical staff
- Requires 2+ chronic conditions
- Includes development and revision of a care plan
- 2025 National Average Reimbursement: $42.84
99491 – CCM by Physician or QHP
- 30+ minutes/month personally by a provider
- Same care plan and condition requirements as 99490
- Reimbursement: $74.26
99439 – Additional CCM Time
- Add-on for each additional 20 minutes after 99490
- Replaced G2058 in 2022
- Reimbursement: $38.00
99487 – Complex CCM
- 60+ minutes/month
- Requires complex decision-making and substantial care plan revision
- Reimbursement: $94.68
99489 – Add-On for Complex CCM
- Additional 30 minutes beyond 99487
- Reimbursement: $45.00
Note: CPT codes 99490 + 99439 and 99491 + 99439 are often billed together for standard CCM. Codes 99487 + 99489 are used for complex cases involving intensive coordination.
How Care Plans and Codes Work Together
The time spent building and updating care plans is reimbursable under CCM codes. Each patient interaction—including updating goals, medication adjustments, and patient education—counts toward monthly time requirements.
Regular care plan updates are crucial. They should reflect:
- New symptoms or condition changes
- Lifestyle or medication adherence issues
- Shifts in social determinants of health
- Patient feedback or new goals
TimeDoc Health’s EHR-integrated platform allows care teams to update care plans directly from the patient chart while meeting CMS compliance standards.
Simplify Your CCM Program with TimeDoc Health
Building and scaling a CCM program doesn’t have to overwhelm your team. With TimeDoc Health, you get:
Automated care plans preloaded for common conditions
Accurate time tracking and billing workflows
Secure EHR integration
Physical and digital care plan delivery
Supplemental care coordination staff if needed
Whether you’re starting small or managing a large patient panel, we help you deliver high-quality care and achieve sustainable program growth.
Ready to Scale Your CCM Program?
Request a personalized demo to see how TimeDoc Health can simplify care planning, improve compliance, and maximize your CCM reimbursement.