April 16, 2025
Casey Johnson
Introduction: Chronic Care Management Takes Center Stage
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Did you know that more than 60% of Americans suffer from at least one chronic disease, with 40% of those battling two or more chronic diseases? For patients like these, chronic care management (CCM) can dramatically help them sustain better health for a longer period of time. Receiving coordinated chronic care services outside of a physician's office allows patients to engage and access the valuable, multi-disciplinary medical support and services that can positively impact their health while reducing the expenses and lag time associated with visiting multiple clinicians across multiple specialties more readily. Clinician and organization efficiency can also improve as this approach allows practitioners and their teams to provide excellent care while better ensuring they have time available for other care demands and needs.
CCM delivers even more benefits. Medicare and other large payers have embraced chronic care management. Such growing support has resulted in this emerging service delivery to quickly become an established healthcare model. With more than 67 million Americans enrolled in Medicare or Medicare Advantage plans, CCM is a viable new revenue stream for participating organizations. It's evident that the Centers for Medicare & Medicaid Services (CMS) views CCM as a service that provides significant value to patients and one that it has and will continue to support going forward.
If you are considering launching a CCM program or expanding an existing one, it's critical to understand some key principles. Be sure to consider the evolution of the care model, CMS guidelines for coding and billing, and best practices for getting started. We'll walk you through these points — and more — in this comprehensive guide.
Chapter 1: Overview of Chronic Care Management
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Implementing a successful chronic condition management program is not inherently straightforward. To build a solid care model, you'll want to gain an understanding of the evolution of CCM, coding guidelines, and foundational concepts.
The purpose behind the inception of chronic care management was to provide a means of compensation for physicians and their organizations that were already caring for patients outside of the average office setting. As care teams collaborated outside the confines of a brick-and-mortar facility, patients with persistent and complicated diseases were able to reduce treatment costs while improving their health. Examples of positive patient outcomes include increased access to appropriate medical resources, enhanced communication with members of their care team, reduction in emergency room visits and hospitalization or readmissions, and increased engagement in their own healthcare.
What is Chronic Care Management: Key Concepts
CMS defines chronic care management as:
Care coordination services done outside of the regular office visit for patients with multiple chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbations / decompensation, or functional decline. These services are typically non-face-to-face and allow eligible practitioners to bill for at least 20 minutes or more of care coordination services per month.
In addition to chronic care management, common care management services include remote patient monitoring (RPM) and transitional care management. (Learn definitions of other common CCM and preventive services terms in this glossary.)
To qualify for chronic care management participation, patients must be diagnosed with two or more covered chronic health conditions that are expected to last for at least 12 months or until the death of the patient.
Under CCM, the patient's care team can bill for time spent managing patients' conditions, usually via services provided outside of a typical office visit. These activities can include things like formulating a comprehensive care plan, interactive remote communication and virtual care management, medication management, and coordination of care between providers.
Since the provision of CCM falls under Medicare Part B, both original Medicare and Medicare Advantage plans reimburse practitioners when CCM services are provided to eligible beneficiaries. Other requirements must be met to code, bill, and get paid for CCM. Learn about these rules and more in this Chronic Care Management Coding and Billing Guide.
What is a CCM-Eligible Chronic Condition?
As stated, chronic health conditions that are expected to last for at least 12 months or the lifetime of the patient can typically qualify a patient for chronic care management — if the patient is managing two or more diseases. Importantly, Medicare criteria must be satisfied. There is no set list of what conditions qualify under the criteria, but some common examples include:
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Alzheimer's disease
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Arthritis
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Asthma
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Cancer
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Dementia
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Depression
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Diabetes
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Heart disease
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Hyperlipidemia
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Hypertension
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HIV/AIDS
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Parkinson’s disease
Overview of Non-Complex and Complex CCM
While we will take a deeper dive into coding and billing for chronic care management later in this guide, understanding some coding and billing fundamentals can help one better understand the concept of CCM. The chronic care management service period is one calendar month. This means that practitioners may choose to submit a claim at the conclusion of the service period or after completing the minimum required service time.
Let's examine the basic (i.e., "non-complex") chronic care management codes: CPT 99490 and CPT 99491. Both require that the enrolled patient receiving services has two or more chronic conditions that are expected to last at least 12 months or until death; the chronic condition must place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; and a comprehensive care plan must be established, implemented, revised, or monitored. Finally, patients must provide explicit consent to enroll them in a CCM program.
When Medicare created the CCM program, the maximum time allotment eligible for reimbursement was limited. To encourage practitioner participation in CCM, and in response to requests of fairer compensation, time allotments were expanded in 2020 and can be billed with other CCM codes. Complex CCM is for patients with two or more qualifying conditions who require more clinical staff and physician time. Complex CCM is billed under CPT 99487 and CPT 99489.
It's important to note that while physicians, certified nurse midwives, clinical nurse specialists, nurse practitioners, and physician assistants may all bill for CCM services, only a single practitioner may receive reimbursement per patient for CCM services for a given calendar month. Additionally, this practitioner must only report either non-complex or complex CCM for a given patient for the month.
The 2022 Physician Fee Schedule final rule delivered a significant increase in reimbursement for some chronic disease management services and finalized the addition of new CCM CPT codes. To learn more about the substantial changes to CCM, watch this webinar, which outlines the final rule's most significant developments related to care management and telehealth.
To understand more about the evolution of CCM and its coverage, let's review the current landscape through a historical lens.
Growing Support for Chronic Care Management
The increase in reimbursement is just one way CMS has demonstrated its support for chronic condition management in recent years. The 2022 proposed rule identified several ways CMS has strived to support CCM in the past, including the 2014 ruling to finalize a unique payable HCPCS code for CCM, HCPCS GXXX1, and the 2015 adoption of separate payment for CCM services under CPT 99490.
CMS has continued to build on support for CCM reimbursement over the years in the following ways:
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For 2017, CMS adopted complex chronic care management (CCCM) CPT codes 99487 and 99489.
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In the 2019 Physician Fee Schedule final rule, CMS adopted new CCM CPT code 99491. This code reimburses physicians for performing 30 minutes of CCM care a month.
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In the 2020 final rule, CMS established payment for an add-on code to CPT code 99490 by creating HCPCS code G2058. CMS also created two new HCPCS G codes: G2064 and G2065.
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In the 2021 final rule, CMS finalized a replacement code for HCPCS code G2058: CPT 99439.
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In 2022, CMS added coverage for the following five new CPT codes: CPT 99437, CPT 99424, CPT 99425, CPT 99426, and CPT 99427.
To stay up to date with CMS updates to CCM follow our blogs under the topic of CCM.
Chronic Care Management in Hypertension Management
To gain a better understanding of how chronic care management is benefiting patients, providers, and our healthcare system as a whole, let's look at how it's being used for one particularly common chronic disease.
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Hypertension arises when blood pressure begins to rise on a consistent basis, and too much force starts pushing against fragile blood vessel walls. More Americans than ever before (in fact, more than 100 million) have often-silent chronic high blood pressure, which leads to serious secondary health issues, such as heart attacks, strokes, and even heart failure.
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Of the Americans who have been diagnosed with hypertension, only about one-quarter have the condition under control. With the lack of obvious symptoms, hypertension is often taken and treated less seriously than it should be. Practitioners have long encouraged their patients to change this thinking and self-monitor hypertension symptoms from home.
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While self-monitoring is good, having patients log readings and take prescription medicine doesn't always provide the direct oversight or support that many people need to stay on track with hypertension monitoring and management. Practitioners and their clinical teams also found themselves spending countless hours coaching their patients outside of normal office visits — up until recently, that time spent wasn't reimbursable by most payers or Medicare. That's where chronic care management for hypertension management comes in.
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CCM provides a better method for practitioners to provide quality and supportive wraparound care for patients while also receiving fair compensation.
With earlier treatment and better management of hypertension using CCM, patients can experience drastically improved outcomes — and providers can finally be appropriately reimbursed for their working supporting patients with hypertension. With so many benefits to be gained from chronic care management, one might assume that widespread adoption is pervasive. That seems to be the case only when practitioners understand the value of implementing a program.
Chapter 2: Foundation for Chronic Care Management Success
Success with chronic care management begins with an organization committing to launching a program and building its foundation, which includes everything from developing workflows to staff training to identifying the software platform that will help power the program (discussed later in this chapter). But all this work will be naught if patients do not understand and buy into the program — and either withhold their consent to join the CCM program or eventually opt out if they do not recognize the value. In other words, patient education when working to enroll patients in your CCM program is a pivotal factor for success.
One potentially sensitive topic that you will want to ensure is covered before patients are enrolled is their likely expenses for participation in CCM. It often falls to practitioners to educate patients about the overall value of consenting to a chronic care management program. Read on to learn what patients should understand about the personal financial investment that's likely to be required — and why that investment is likely to be very worthwhile.
Chronic Care Management Patient Costs: Justifying Their Investment
It's important to put financial terms in proper perspective. For example, out-of-pocket expense concerns must be balanced with a greater understanding of the overall value of chronic care management. Specifically, patients might be less reluctant if they know that enrollment and participation are likely to save them money — potentially substantial money — in the long run. Some organizations offer financial assistance programs for those who need it most to help ensure more patients can benefit from chronic care management.
Getting patient buy-in for CCM depends on illustrating tangible reasons that it can be beneficial. Here are the five examples that you can share with patients.
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Less money spent on hospital bills — If CCM can prevent the need for even just one hospitalization, it will easily justify the price tag. According to Consumer Health Ratings, the cost of a hospital stay for all diagnoses in 2021 is estimated to average over $13,000, excluding physician fees.
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More efficient management of medications and symptoms — With effective chronic care management, practitioners can pinpoint what medications work and eliminate potentially harmful and unnecessary drugs. Considering that Americans spend more on prescription drugs than anyone else in the world, this can represent significant savings. And with more dialed-in medications and more effective medication management comes better controlled symptoms.
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Better access to the care team and other resources — Eliminating complex logistics that come with office visits, CCM reduces the likelihood that time-sensitive information will lag. Chronic care management also provides a direct link to the patient's care team, better ensuring that when a care or medication issue or question arises, the patient can receive the support and answers they need directly from a knowledgeable source.
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Convenience and improved quality of life — A CCM program meets a patient where they are located. Patients can utilize telehealth services, such as remote patient monitoring, through secure platforms that provide current information about care and vitals. This level of coordination allows the healthcare team to make more informed decisions and prompts the patient to be more accountable while reducing the number of trips to the office and amount of time patients need to spend on the road. These clinical gains could easily prevent the need for emergency care and urgent care, and the additional high costs associated with such experiences.
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Improved coordinated care — According to the University of New Hampshire, duplication of services, such as labs and imaging, wastes as much as $20 billion in healthcare costs annually. Increasing effective care coordination decreases the likelihood of duplicated services.
Creating a Chronic Care Management Patient Brochure
To reinforce the patient education process, practitioners can create educational brochures for distribution during in-person visits. Research has shown they can provide great benefits. While some patients may prefer to research information online, many others still rely on printed materials like brochures. Additionally, a well-designed brochure can be distributed in print and electronically.
Let's examine some key components that should be in an effective chronic care management brochure.
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Chronic care management definition — Consider providing a definition for chronic care management — preferably one written in plain language.
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Chronic care management eligibility — Educating patients on their potential eligibility may motivate them to inquire about participation in a CCM program and increase their interest in participating.
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Time commitment — It's a good idea to demonstrate exactly how CCM can make a patient's life more convenient by reducing trips to the office and granting them access to telehealth services.
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Cost of chronic care management — In the brochure, it's wise to explain to patients that CCM is covered by Medicare and typically incurs minimal out-of-pocket cost. Encourage them to talk to a representative from your organization who can give them a more personalized breakdown of estimated costs.
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Who is involved — Patients should understand the concept and value of having a chronic care management team who will help them in the program. Explain how having a coordinated care team will function as a support network, allowing patients to get better care when they need it.
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How chronic care management helps achieve healthcare goals — Top reasons why patients should enroll in a CCM program include helping them stay healthier and work toward healthcare goals. It's best to spell this out in the brochure. Use concise and clear language that will help them draw the parallels between CCM services and their personal health and wellness. Take into consideration if your patient population needs the information in multiple languages.
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Getting started with chronic care management — Help patients overcome the potential obstacle of taking the first step toward enrolling in chronic condition management by clearly communicating what actions they will need to take. It's helpful to anticipate their questions, such as: "Do I need to initiate a conversation with their primary care provider?" and "Is there an onsite program coordinator or patient care advocate, such as a nurse case manager, I should speak to?"
The main takeaway: When creating the content for your brochure, keep the information simple, jargon-free, and easy to follow. Providing just enough information to stimulate interest and facilitate a conversation with you will work best for patients and your program.
Note: If your organization is leveraging CCM as part of a broader comprehensive care management — also known as "virtual care management" — program, this blog post provides some tips on how to explain comprehensive care management to patients.
Chronic Care Management Companies: Choosing the Right Software
The right chronic care management software can make or break a CCM program. It's that simple. And that's why due diligence is essential when researching your CCM software options. Let's look at some of the key qualities to consider when researching and eventually selecting CCM software so that you can make a wise decision.
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Security — Cybercrime is a fact of life. An article published by The HIPAA Journal revealed that 95% of organizations had experienced a breach by 2023, and each stolen healthcare record costs healthcare institutions an average of $165. To help avoid the potential bankrupting effects and other damaging fallout from a serious breach, review the security features of the chronic care management software you're considering and ask vendors about the training tactics they use to better ensure data security and protect sensitive patient health and financial information.
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Compliance and reporting — With Medicare and commercial payers, coding, billing, and reporting rulescan change with little notice. Make sure your CCM vendor has established procedures to stay current with compliance
guidelines, including complying with HIPAA requirements. Look for a program that makes useful reports accessible and data reporting easy. -
Integration — To avoid redundancy, find out if the CCM software you're considering integrates with other software solutions, including whether it smoothly integrates with your EHR system. It should include clear dashboards to identify the current status of each patient and save you time, rather than adding duplicate tasks to your workflow.
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Automation — CCM software should promote efficiency. Look for solutions that automate these kinds of processes:
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Identifying CCM-eligible patients within your EHR
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Inputting patient data collected and transmitted via CCM technology directly into patient charts
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Streamlining billing through intuitive coding processes
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Patient churn management — The number of people with chronic conditions who are enrolled in Medicare is expected to balloon. The right chronic disease management software should help you identify these patients as they become eligible for your CCM program. Furthermore, the system should enable you to confirm and document when patients meet the qualifying requirements for CCM
As a valuable bonus, a good chronic care management software program can also support other care management services, such as remote patient monitoring — which is positioned to play a growing role in chronic condition management — and behavioral health integration.
Choosing the right chronic care management software to use and vendor to work with is crucial. Not only does software make the delivery CCM easier, but it also positively affects your return on investment. And the right vendor will collaborate with you to establish and grow your program, provide exceptional customer services, and help you maximize the value and return on investment of your technology purchase.
Of course, another factor that can directly impact your bottom line is your understanding and exception of chronic care management coding and billing.
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Our billing guide offers vital information on new CPT codes, billing flow, service requirements and reimbursement.
Chapter 3: Coding and Billing for Chronic Care Management
The federal government has been increasingly supportive of care management programs. However, it is also more closely scrutinizing chronic care management reimbursement. It's important to ensure that you appropriately and consistently follow the rules of CCM codes and CCM billing. Expect more auditing to investigate causes of overpayment associated with incorrect billing of the service (more about this later in the chapter).
Rules for CPT 99490 and the Other Chronic Care Management Codes
Let's explore the most common and frequently used chronic care management CPT codes.
CPT 99490 and CPT 99491: Initial CCM Codes
We start our discussion about chronic care management coding and billing with the basic chronic care management CPT code, introduced in 2015, and its sister CPT code, which became effective in 2019. Together, these two CCM codes are sometimes referred to as the non-complex CCM codes.
CPT 99490
Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, with the following required elements:
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Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
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Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline
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Comprehensive care plan established, implemented, revised, or monitored
CPT 99490 assumes 15 minutes of work by the billing practitioner each month.
CPT 99491
Chronic care management services, provided personally by a physician or other qualified healthcare professional, at least 30 minutes of physician or other qualified health care professional time, per calendar month, with the following required elements:
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Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
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Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline
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Comprehensive care plan established, implemented, revised, or monitored
Difference Between CPT 99490 and CPT 99491
The between CPT 99490 and CPT 99491 is subtle but significant. Under CPT 99490, clinical staff supervised by a physician or other qualified healthcare professional can perform CCM for billing purposes. CPT 99491, on the other hand, compensates physicians or other qualified healthcare professionals for time spent on CCM-related care and requires them to provide such care personally. CPT 99491 also requires a minimum of 30 minutes a month of CCM versus the 20 minutes required as per CPT 99490.
CPT 99439 and CPT 99437: CCM Add-On Codes
These are two CCM add-on codes: CPT 99439, which replaced HCPCS code G2058 in 2021, and CPT 99437, which was added for 2022 in the 2022 Medicare Physician fee schedule final rule.
CPT 99439
Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month.
When to Report CPT 99439
CMS established payment for HCPCS code G2058 in its 2020 physician fee schedule final rule and then decided one year later to replace G2058 with CPT 99439. This code can be reported no more than twice per calendar month with CPT 99490 to capture additional care that exceeded the established 20-minute time allotments.
CPT 99437
Chronic care management services each additional 30 minutes by a physician or other qualified health care professional, per calendar month.
When to Report CPT 99437
As an add-on code for CPT 99491, it should only be billed for time spent beyond the initial 30 minutes spent providing services under 99491.
CPT 99487: Initial Complex CCM Code
Introduced in 2017 when the CCM benefit was expanded, this is a more complex CCM code. As we define in our glossary and noted earlier in this guide, complex CCM is intended for those patients with "two or more qualifying conditions who require more clinical staff and physician time" than non-complex CCM. In other words, these are patients who must also require moderate- to high-complexity medical decision-making. Let's look at the main CCM code.
CPT 99487
Complex chronic care management services, with the following required elements:
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Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
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Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
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Establishment or substantial revision of a comprehensive care plan
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Moderate or high complexity medical decision making
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60 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month
CPT 99489: Complex CCM Add-On Code
Now let's look at the add-on code to CPT 99487.
CPT 99489
Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (list separately in addition to code for primary procedure).
When to Report CPT 99489
As the end of the description for CPT 99489 suggests, this code should not be listed on its own. Rather, report in conjunction with CPT 99487 when a patient requires an additional 30 minutes of care in the month. This comes on top of the 60 minutes already covered under CPT 99487.
Table: CY 2024 Chronic Care Management CPT Codes
|
CPT Code |
Service |
Staff Type |
Care Management Time |
Billing Units/Month (Max) |
Reimbursement |
|
99490 |
CCM |
Clinical |
First 20 minutes |
1 |
~$60 |
|
99439 |
CCM |
Clinical |
Each additional 20 additional |
2 |
~$46 |
|
99491 |
CCM |
Physician or qualified healthcare professional |
At least 30 minutes |
1 |
~$82 |
|
99437 |
CCM |
Physician or qualified healthcare professional |
Each additional 30 |
No limit |
~$58 |
|
99487 |
Complex CCM |
Clinical |
First 30 minutes |
1 |
~$132 |
|
99849 |
Complex CCM |
Clinical |
Each additional 30 minutes |
No limit |
~$71 |
Other Relevant Care Management Codes
In addition to these chronic care management codes, there are complementary services that are often billed with CCM by organizations that have developed a comprehensive care management program. Three examples are remote physiological monitoring (sometimes referred to as remote patient monitoring or RPM), behavioral health integration (BHI) care management services, and, less frequently, principal care management (PCM). Read more about these codes here or reference this helpful CMS resource. You can also learn more by reading this Medical Economics column written by Prevounce's Daniel Tashnek.
OIG Audit Reveals Chronic Care Management Overpayments
In mid-2021, the federal Office of Inspector General (OIG) conducted an audit covering nearly 8 million claims submitted by physicians and more than 240,000 claims submitted by hospitals for non-complex and complex chronic care management services provided in 2017 and 2018.
The results of this audit have short- and long-term implications for providers of CCM services as well as software vendors. Here are the most important things to understand about the audit and its consequences:
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Why OIG performed the CCM audit — The agency specifically focused on whether payments made by the Centers for Medicare & Medicaid Service (CMS) for the two types of chronic care management services — non-complex and complex — during 2017 and 2018 complied with federal requirements.
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What the chronic care management audit found — The audit determined that there were nearly $2 million in overpayments associated with about 50,000 claims for non-complex and complex chronic care management services rendered during 2017 and 2018. From these claims, beneficiaries' cost sharing totaled up to about $541,000. According to OIG, the overpayment errors were attributed to CMS lacking claim system edits to prevent and detect overpayments.
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What OIG recommended — Among several recommendations from the agency, these are some of the standouts:
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Direct Medicare contractors to recover the overpayments within the reopening period.
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Instruct providers to refund up to ~$541,000 which beneficiaries were required to pay.
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Notify appropriate providers to exercise reasonable diligence in identifying, reporting, and returning overpayments in accordance with the 60-day rule. The 60-day rule, created by the Affordable Care Act, requires providers to use reasonable diligence to identify overpayments via proactive compliance activities to monitor overpayments and investigate potential overpayments in a timely manner.
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Implement claim system edits to prevent and detect future overpayments for chronic care management services.
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What does this mean for practitioners? You'll need to step up your oversight of your chronic care management programs and better ensure you are coding and billing properly — or face potential violation penalties. Keeping your CCM program compliant is not difficult, but it requires you to be mindful of the requirements when you set up your clinical and administrative workflows. Choosing a CCM software provider that makes compliance a top priority is extra insurance during periods of increased scrutiny and change.
Conclusion: Why the Time Is Now for Chronic Care Management
Chronic care management provides patients ongoing health and wellness support, greater access to appropriate medical resources and care team members, and a reduced need for emergency care. Meanwhile, practitioners experience improved care coordination, better patient satisfaction and engagement, and an opportunity to boost revenue. It's clear that CMS has affirmed support for CCM as a long-term patient care and coverage strategy by expanding reimbursements. In fact, there may never be a better time to add or grow a chronic care management program.
The bottom line: Chronic care management provides streamlined wraparound care for patients — and it's also good for business. So how does your organization take advantage of this growing opportunity?
An effective CCM program requires practice managers, practitioners, and clinical staff to work together to identify and enroll eligible beneficiaries and then establish processes that work well for everyone. If you are considering adding a CCM program or growing an existing program, you may also want to investigate launching other care management programs, such as remote patient monitoring.
With many complex moving pieces to juggle, you may find launching a CCM program can be difficult. But it doesn't have to be.
Prevounce has taken the lead to create user-friendly solutions that streamline the provision of chronic care management services, and we can help you build the components of your CCM program and navigate the challenges you will encounter along the way. With the right CCM software and vendor to support your efforts, you can keep the focus on delivering patient care and expanding your patient base. If you'd like to learn more about how we are helping organizations nationwide deliver CCM services, reinforce compliance, and safeguard security, book a meeting here.
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Download the CCM Billing Guide
Everything You Should Know About Coding and Billing for CCM
Download the CCM coding and billing guide to learn more about:
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Practice, patient, and monthly CCM billing requirements
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Chronic care management coding guidelines
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Coding and billing for behavioral health integration (BHI)
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Coding and billing for principal care management (PCM)
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