Chronic Care Management (CCM) | Rules and Requirements
Learn Medicare's requirements for value-based care programs.
What is CCM?
Medicare reimburses providers for the provision of coordinated care services to patients with two or more chronic conditions.
CCM is a calendar month program that tracks the patient’s health issues through a comprehensive patient-centered care plan, reimbursing for non-face-to-face interactions related to the patient’s health.
Non-face-to-face interactions include (but are not limited to) monthly clinical review, telephone calls, referrals, and prescription refills.
Types of chronic conditions
Examples of the most common chronic conditions in the United States include diabetes, high blood pressure, hypertension, heart disease, heart failure, COPD, and asthma.
Components of CCM
The patient must have 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.
A comprehensive care plan established, implemented, revised, or monitored in a certified EHR with a copy available to the patient.
Patient consent (verbal or signed)
24/7 patient access to a member of the care team for urgent needs
Enhanced non-face-to-face communication between patient and care team
At least 20 minutes of clinical staff time per calendar month spent on non-face-to-face CCM services directed by a physician or other qualified health care professional
Who can deliver CCM care?
Physicians and the following non-physician practitioners may bill CCM services:
Certified Nurse Assistant (CNA)
Certified Medical Assistant (CMA)
Clinical Nurse Specialists (CNS)
Nurse Practitioners (NP)
Physician Assistants (PA)
Health Coaches (in some areas)
Note: Only one practitioner may be paid for CCM services for a given calendar month. The practitioner can only submit one CCM claim per month.
What are CCM's CPT codes?
You can use the following reimbursement structure: