What is CCM?

In recognition of the importance of chronic disease management and the impact that it has on health care expenses and outcomes, the Centers for Medicare & Medicaid Services (CMS) has started paying monthly reimbursements for chronic care management (CCM) services. Released on January 1st 2015, CPT code 99490 pays approximately $42 per month to providers who deliver 20+ minutes of non-face-to-face care management services to eligible Medicare beneficiaries with 2 or more chronic conditions. As quoted by the New England Journal of Medicine, “A physician caring for 200 qualifying patients could see additional revenue of roughly $100,000 annually.” The Final Rule of the 2015 Medicare Physician Fee Schedule included the new CPT 99490, defined as:

“Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements; multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored.”

What Activities Count Towards the 20 Minute Requirement?

Any non-face-to-face care management and coordination service provided on behalf of an enrolled beneficiary by a provider or clinical staff member counts.

  • Phone calls, emails, and messaging with the patient and caregiver

  • Lab, report, and image review

  • Care plan creation, revision, and review

  • Medication reconciliation, overseeing patient self-management of medication

  • Chart documentation

  • Medication refills

  • Remote monitoring of physiological data

  • Referring to and consulting with other providers

  • Post-discharge follow-up

Physicians and clinical staff members have always spent a significant amount of time on these activities, but haven’t been reimbursed for them, until now.



Physicians, regardless of specialty, advanced practice registered nurses, physician’s assistants, clinical nurse specialists, and certified nurse midwives are all eligible to bill Medicare for CCM. While the billing provider must oversee the CCM services, they are not required to be present for the work to be done.


CMS has left the ruling open to discernment by the provider. The guideline simply requires:

✓ Two or more chronic conditions expected to last at least 12 months, or until the death of the patient
✓ Chronic conditions that place the patient at significant risk of death, or acute exacerbation/decompensation

CMS maintains a Chronic Condition Warehouse with 22 chronic conditions listed to provide researchers with beneficiary, claims, and assessment data, however, it is not an exclusive list.


In order to bill for CCM, providers must get the patient’s written consent, confirming that the following has been explained to the  beneficiary:
✓ An overview of CCM
✓ How the CCM service may be accessed
✓ That only one provider can provide CCM services at a time
✓ That information will be shared among all the patient’s providers
✓ The patient can terminate the CCM service at any point in time by revoking  consent
✓ The patient will be responsible for any associated copayment or deductibles

Once the consent form is signed, a copy must be stored in the patient’s medical  record.



In order to bill Medicare, providers must meet several new technology and services requirements. These services can be fulfilled by the provider or performed by a subcontractor.

  • 24/7 access to clinical staff to address urgent chronic care needs

  • Continuity of care through access to an established care team for successive routine appointments

  • Ongoing care management, including medication reconciliation and regular assessment of a patient’s medical, functional, and psychosocial needs

  • A comprehensive, patient-centered care plan that is electronically shared with all of the patient’s providers

  • Management of care transitions between and among all providers and settings

  • Coordination with home- and community-based clinical service providers

  • Patient and caregiver access, with enhanced opportunities to communicate with the care team

After over a year and a half of working with providers on Medicare's new CCM program, we've come to learn that there are two main obstacles to running a CCM program that is beneficial to both the practice and its patients.



Health care organizations do not have the software functionality required to run an efficient and compliant CCM program at the scale necessary to generate significant value.



For some organizations, existing clinical staff members do not have enough capacity to serve the volume of patients necessary to generate an attractive return on the investment.