About Chronic Care Management (CCM)

CCM is a Medicare Part B benefit designed for individuals with two or more chronic conditions. Supervised by a physician, nurse practitioner, or physician assistant, CCM helps patients manage their conditions outside of regular doctor visits. Services include care coordination, medication management, and access to community resources, all aimed at improving health outcomes and reducing hospital visits.

CCM provides a wide range of personalized support services for Medicare beneficiaries, including:

• Care management & transitional care
• Regular patient communication (phone, in-person, or online)
• Community resource referrals
• Health coaching & disease self-management education
• Preventive health counseling & fall risk interventions
• Medication & symptom management

CCM services extend beyond the doctor’s office and can be delivered:

• At home
• By phone or online
• In community health settings
• Through coordination with healthcare providers

Before CCM services begin, Medicare requires a face-to-face visit for new patients or those not seen in the past year. This visit can be:

• An Annual Wellness Visit

• A Preventive Physical Exam

• A Transitional Care Visit

• Another qualifying evaluation and management visit

Once the initiating visit is completed, a comprehensive care plan is developed to guide the patient’s CCM services.

The care plan is developed by the clinical team, including staff from healthcare providers and community-based organizations, under the supervision of a qualified physician, nurse practitioner, or physician assistant.

While CCM services can be delivered via phone or online, they are not considered telehealth services under Medicare regulations.

CCM services must be delivered by clinical team members under the general supervision of a physician, nurse practitioner, or physician assistant. While no specific credentialing is required, team members should have experience in chronic disease management and care coordination.

There are no national credentialing standards for health coaches in CCM. However, training through the National Board for Health and Wellness Coaching or similar programs is recommended. Medicare providers may determine appropriate training requirements in collaboration with community-based organizations.

What is the difference between CCM and Complex CCM?

• CCM (CPT Code 99490): Covers 20 minutes of clinical staff time per month for ongoing care management.

• Complex CCM (CPT Code 99487): Covers 60 minutes per month and involves moderate to high-complexity medical decision-making.

• Add-on Code (99489): Allows for an additional 30 minutes beyond the initial 60 minutes for Complex CCM.

No. A Medicare beneficiary can only receive one type of CCM (regular or complex) per month, and only one provider can bill for the service.

Is patient consent required for CCM?

Yes. Patient consent can be verbal or written, but verbal consent must be documented in the electronic health record (EHR).

Is an electronic health record (EHR) required for CCM?

Yes, providers must use a Medicare-certified EHR to document CCM services. However, community-based organizations (CBOs) partnering with providers are not required to use an EHR but must ensure proper documentation is shared with the supervising provider.

Can multiple CCM service units be billed per month?

No. Only one unit of CCM (20 minutes) can be billed per month unless providing Complex CCM.

Is there a copay for CCM services?

Yes. Medicare covers 80% of the cost, and patients are responsible for a 20% copay unless they have Medicaid or supplemental insurance that covers the remaining balance.

CCM & Other Medicare Services

Can patients receive CCM along with Diabetes Self-Management Training (DSMT)?

Yes. CCM can be provided before, during, and after DSMT to support ongoing chronic disease management. Integrating CCM with other Medicare benefits allows for comprehensive care and better patient outcomes.