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Chronic Care Management

A Comprehensive Guide to
Chronic Care Management

Learn about the benefits and requirements of this Medicare program.



What is Chronic Care Management?

A monthly touchpoint to coordinate patient care

CCM is a Medicare Part-B program for patients with two or more chronic conditions. Clinical staff engage patients for at least 20 minutes per month to coordinate care activities.

Studies have shown that CCM programs can reduce hospital admissions and cut health costs in the long term. Providers are also reimbursed per patient for offering the service. 

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Patients benefit from coordinated care and increased engagement

Patients work with care managers to achieve desired health outcomes. This all revolves around a patient-centered care plan.

CCM services include a monthly clinical review, telephone check-ins, physician reviews, referrals, prescription refills, chart reviews and scheduling appointments or services.

Qualified providers span care teams

CCM billing must be directed by a provider with an NPI number. That said, a diverse set of licenses can deliver the program, including:

  • Physicians
  • Physician assistants
  • Nurse practitioners
  • Certified nurse midwives
  • Clinical nurse specialists
  • Pharmacists

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Eligibility depends on requirements

A patient must have two or more chronic conditions to enroll in a CCM program. These diseases must: 

  • Be expected to last at least 12 months or until end-of-life
  • Post a risk of death, acute decompensation or functional decline
  • Be noted by the provider 12 months prior to enrollment

How do patients enroll in CCM?

Enrollment is completed at an in-person evaluation or Annual Wellness Visit. Written or oral consent must be documented.

The provider should explain to the patient:

  • How CCM can benefit them
  • Medicare Part-B's 80% coverage with co-pay
  • That they can opt out at any time
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Understanding Chronic Care Management CPT codes:
99490, 99491, 99439, and more

2024 - CCM - Chart 1 - Final

Different CPT billing codes reflect specific categories of CCM.  The qualifying determinants are who provides program services, complexity of medical decision-making, and the length of time spent with the patient.


CPT Codes 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.  

  • 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 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 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 a Medicare audit, you will want to show the correct code was applied based on the compatible situation.

To bill for CCM, providers must meet specific requirements

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

Providers can successfully submit
Chronic Care Management claims by:

CCM Rules - Provider Expectations-1

How to start a CCM program

Before starting a chronic care program, it's important to consider: 

  • Your plan to enroll and deliver services to patients
  • Hiring a certified care manager
  • Targeting a specific population or conditions
  • Using software to manage care planning and billing

Initial steps to launching a CCM program

Apart from understanding CCM's rules and requirements, providers should:

Care managers engage patients and facilitate CCM program services

Care managers play a crucial role in delivering care management services to patients. They conduct a majority of patient engagement and execute nearly all program services.

Chronic Care Management can
promote value-based care

An aging, chronically ill population calls for wide adoption of CCM

CCM can be a versatile tool to maximize care quality and performance.

Though it's a fee-for-service program, CCM can help providers address value-based care objectives without sacrificing financial stability.

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Patient engagement is
essential to closing care gaps

Care gap closure isn’t about checking a box.

CCM programs can help patients understand the value of prevention throughout every phase of life.

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SMART goals can personalize care planning for disease management

Goal-oriented care engages patients in identifying their personal objectives and aligning their care with these desired outcomes. 

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Payors and providers use CCM
to reduce healthcare costs

According to Highmark Health, payors and providers can use CCM to save more than $800 per case, reducing readmission and inpatient days, as well as lowering post-acute utilization rates.

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MetaPhy Health uses software to streamline chronic care delivery

Since 2017, ThoroughCare has helped MetaPhy Health optimize care delivery for patients with multiple chronic conditions. 

Learn how MetaPhy Health uses our care coordination platform. 

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CCM can be combined
with other Medicare programs

This can further support patient outcomes and generate additional reimbursement.

Providers can partner with pharmacies for program delivery

Primary care shortages, value-based contracting and increasing chronic illness call for pharmacists to have an expanded role. 

Through partnerships, providers can work with pharmacies to streamline care management and improve patient engagement.

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ThoroughCare streamlines
Chronic Care Management

Our software platform is intuitive and designed for CCM’s rules and requirements. ThoroughCare can help providers:

  • Facilitate patient consent and enrollment
  • Manage the entire CCM function
  • Create and maintain goal-driven care plans
  • Simplify claim submission and documentation requirements
  • Integrate with leading EHRs for holistic patient records

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