.jpg "Daniel Godla")
What is Chronic Care Management?
Chronic Care Management (CCM) is a preventive health program that helps patients mitigate their chronic conditions. As covered by Medicare Part B, providers should understand what CPT billing codes matter to the program and how they are used. This can help your organization avoid denied claims and enhance care.
CCM is covered for Medicare Part B patients with a small co-pay. This monthly engagement program offers patients the benefits of personalized care plans and assisted development of self-management behaviors.
CCM is reimbursable under Medicare’s Physician Fee Schedule, paying various rates.
Chronic Care Management CPT codes:
99490, 99487, 99491, and more
Different CPT billing codes reflect specific types of CCM. The crucial qualifying determinants are who provides program services, complexity of medical decision-making, and the length of time spent with the patient.
CPT codes 99490 and 99439 for non-complex Chronic Care Management
Billing code assignment is based on the complexity of medical decision-making.
As shown in the graphic above, CCM billing codes specify Complex and Non-complex chronic care services. Within these categories, codes further reflect different lengths of time spent with patients and the level of physician involvement required.
In some instances, Non-complex CCM can be provided by clinical staff.
For Non-complex CCM, the following CPT codes can be used to account for reimbursement, based on all program requirements being fulfilled (more information on this later in the article).
- CPT code 99490 for 20 minutes of billable time
- CPT codes 99490 + 99439 for 40 minutes of billable time
- CPT codes 99490 + 99439 (x2) for 60 minutes of billable time
Two ICD-10s must be presented when billing for chronic care services as the requirement for CCM includes two or more present conditions.
CPT codes 99491 and 99437 for physician-driven, non-complex Chronic Care Management
The following codes are designed for non-complex chronic care in which the provider or non-physician practitioner (NPP) is heavily involved. They cannot be billed concurrently with standard CCM CPT codes (reviewed in the prior section).
The value of physicians’ time is reflected in these non-complex, physician-driven codes as CCM services are not reliant on clinical staff:
- CPT code 99491 for 30 minutes of billable time
- CPT codes 99491 + 99437 for 60 minutes of billable time
CPT codes 99487 and 99489 for complex chronic care
The following billing codes apply for complex care:
- CPT code 99487 for 60 minutes of billable time
- CPT codes 99487 + 99489 for 90 minutes of billable time
It is important to note the distinction between CPT code 99487, which accounts for 60 minutes of complex chronic care, versus the two CPT codes (99491 and 99437) that account for 60 minutes of physician-driven, non-complex chronic care.
In the case of an audit, you will want to show the correct code was applied based on the compatible situation.
How CMS determines CCM rates each year
Understanding how Medicare calculates physician reimbursement rates is at the center of answering how much Medicare pays for CCM. CMS calculates reimbursement rates for CCM services using a variety of factors, including:
- CPT billing codes – specific codes that reflect the complexity of patient needs and time spent
- Relative value unit (RVU) –reflects the relative time and intensity of each CPT code
- Annual conversion factor (CF) – used to calculate a national average fee
- Geographic practice cost index (GPCI) – adjusts the national average fee to reflect variation in practice costs across the US
The following graphic illustrates the Medicare PFS payment rates formula that is used to establish what physicians and other providers are paid.
About Medicare Chronic Care Management
and its billing requirements
Providers can use CCM to engage patients on a monthly basis between regular appointments.
Delivered through remote interactions, either by phone or a telehealth platform, CCM is billable when at least 20 minutes are spent with the patient performing appropriate tasks.
CCM services can include:
- A monthly clinical review
- Telephone calls
- Physician reviews
- Referrals
- Prescription refills
- Chart reviews
- Scheduling appointments or services
A patient’s CCM eligibility necessitates having two or more chronic conditions expected to last a minimum of 12 months. Additionally, the patient’s doctor must note these conditions 12 months prior to enrollment. They must pose a significant risk of death, acute decompensation, or functional decline.
Individual care plans are created for, and in collaboration with, the patient upon CCM enrollment and determine services rendered. These care plans act as a comprehensive guide to the patient’s goals, health history, and behavior. Medicare Part B covers 80% of this benefit for patients.
Who can provide CCM services?
CCM billing must be directed by a provider with an NPI number. However, clinical staff can administer most of the program, saving physician time and involvement. Eligible providers include:
- Physicians
- Physician assistants
- Nurse practitioners
- Certified nurse midwives
- Clinical nurse specialists
- Pharmacists
Submitting claims to Medicare
Five items are required when submitting a Medicare claim:
- CPT codes for each program you are managing for the patient
- ICD-10 codes tied to each of the conditions you are managing within that program
- Date of service
- Place of service (most often in-office or telehealth)
- National Provider Identifier (NPI) number
It is helpful to know the staff care coordinator assigned to a patient in case of an audit.
Four steps to bill for CCM
- Verify CMS requirements were met for each patient each month
- Submit claims to CMS monthly
- Send an invoice to patients receiving monthly CCM services
- Determine there are no conflicting codes that have been billed
Rural Health Clinics and Federally Qualified Health Centers can deliver Chronic Care Management
CMS allows use of individual care management codes
In 2024, HCPCS code G0511 was updated to cover eight care management programs and 28 other codes. It was also enhanced to allow billing for multiple instances in a given month.
This was how RHCs and FQHCs had to bill for Chronic Care Management. Not anymore.
Prior to the CY 2024 Final Rule, clinicians and healthcare professionals had requested CMS give rural providers and FQHCs access to fee-for-service billing codes.
CMS met this request in creating the CY 2025 Final Rule, which says, “We believe the non-face-to-face time required to coordinate care is not captured in the RHC AIR or the FQHC PPS payment, particularly for the rural and/or low-income populations served by RHCs and FQHCs. Allowing separate payment for CCM services in RHCs and FQHCs is intended to reflect the additional resources necessary for the unique components of CCM services.”
Giving RHCs/FQHCs access to individual billing codes aims to improve payment accuracy and provide clarity about which services beneficiaries receive.
Transition period to billing care management codes
CMS is implementing a six-month transition period to enable qualified rural providers to update their billing systems and procedures. The transition is currently set to end on July 1, 2025; however, it could be extended further. Beginning January 1, 2025, RHCs and FQHCs may begin billing individual HCPCS/CPT codes if they so choose.
CCM with Remote Patient Monitoring
Providers can offer CCM alongside Remote Patient Monitoring (RPM).
Using digital devices, such as a blood glucose monitor, patients can capture their data and use it to inform condition management.
RPM supports its own CPT billing codes, and these can be billed concurrently with CCM, supporting dual reimbursements. However, all RPM service and time requirements must be met separately from CCM.
This is also the case for rural health clinics and federally qualified health centers. Learn more about RPM billing codes here.
CCM with Behavioral Health Integration
Providers can also pair CCM with Behavioral Health Integration (BHI).
BHI is a monthly care management program that helps Medicare beneficiaries address mental health concerns. When offered with CCM, integrated behavioral health supports a collaborative care model that can improve outcomes and reduce cost.
BHI supports its own CPT billing code that can be billed concurrently with CCM. However, all BHI service and time requirements must be met separately from CCM.
This is also the case for rural health clinics and federally qualified health centers. Learn more about BHI billing codes here.
Revenue potential of CCM
For healthcare organizations, care management programs can drive revenue and support cost savings. Below is a general example of how reimbursement for a CCM program could add up.
The final figure in the graphic does not account for complex or physician-driven CCM services, nor does it include additional billable time beyond the 20-minute minimum. Both could produce a higher figure.
Estimate ROI for Chronic Care Management
The MPFS Look-Up Tool allows users to search for pricing amounts, payment policy indicators, RVUs, and GPCIs.
A provider can look up the CCM rates for their region by choosing pricing information, including the CCM codes that apply to them and choosing their Medicare Administrative Contractor (MAC) for a specific locality.
CCM promotes value-based care
CCM programs offer additional provider benefits, beyond direct reimbursement. They can be optimized to report data, engage and motivate patients, and meet specific quality metrics key to value-based care.
CCM enhances patient engagement and improves care coordination. Personalized care planning can be used to establish and track SMART goals, or identify social determinants of health.
Patients benefit from enhanced engagement, as well as access to a care manager. They have a monthly check-in to ask questions, discuss conditions, and access resources.
A CCM program can generate significant revenue just by billing certain CPT codes. However, elements of the program, especially within a larger healthcare system, can also promote a value-based care model.
ThoroughCare simplifies Chronic Care Management
ThoroughCare gives providers the tools and support to make Chronic Care Management effective.
We help providers, based on their specific needs, build Chronic Care Management programs or scale existing services. ThoroughCare supports a comprehensive software platform, clinical expertise to optimize workflows and assistance with data and reporting for quality improvement.
We simplify the process, so providers can focus on engaging patients. ThoroughCare offers:
- Comprehensive care planning tools
- Evidence-based assessments (lifestyle, health risks, behavioral conditions, SDOH)
- Automated billing code assignment with audit trail
- Data integration across EHRs, HIEs, remote devices and advance care plans
- Analytics to report on care performance and operations
*Reimbursement rates are based on a national average and may vary depending on your location.
Check the Physician Fee Schedule for the latest information.