Chronic care management for complex patients
Chronic Care Management (CCM) provides ongoing support for patients with multiple chronic conditions. Build care plans, coordinate between providers, and bill for non-face-to-face care time.
Comprehensive chronic care support
CCM helps you manage patients with two or more chronic conditions through ongoing care coordination.
Care Plan Management
Create comprehensive, personalized care plans for each patient.
Regular Check-Ins
Monthly calls ensure patients stay on track with their health goals.
Care Coordination
Coordinate between specialists, pharmacies, and community resources.
Medicare Reimbursement
Bill CPT 99490, 99439, and 99487 for non-face-to-face care time.
Who qualifies for CCM?
Medicare patients with two or more chronic conditions expected to last at least 12 months qualify for CCM services. Patients with a single chronic condition may qualify for Advanced Primary Care Management (APCM) or Principal Care Management (PCM) instead.
- Two or more chronic conditions
- Conditions expected to last 12+ months
- Conditions place patient at significant risk
- Patient consents to CCM services
- Medicare Part B coverage
Common questions about CCM
What is Chronic Care Management (CCM)?
Chronic Care Management (CCM) is a Medicare-reimbursed service that provides ongoing care coordination for patients with two or more chronic conditions. It includes care plan development, medication management, 24/7 access to a care team, and regular check-in calls, all billable through CPT codes 99490, 99491, and 99487.
Who qualifies for CCM services?
Medicare patients qualify for CCM if they have two or more chronic conditions expected to last at least 12 months, and these conditions place the patient at significant risk of death, acute exacerbation, or functional decline. Common qualifying conditions include hypertension, diabetes, heart failure, COPD, and depression.
What are the Medicare CCM billing codes?
The primary Medicare CCM billing codes are: CPT 99490 (first 20 minutes of clinical staff time, ~$42/month), CPT 99491 (30 minutes of physician or qualified professional time, ~$85/month), and CPT 99487 (60 minutes of complex CCM, ~$93/month). Additional time can be billed with 99439 and 99489. Figures are approximate CY2025 national non-facility averages — rates change each year with the Physician Fee Schedule.
How is CCM different from APCM?
CCM pays for documented clinical staff minutes each month, while Advanced Primary Care Management (APCM) pays a flat monthly rate per patient with no minute thresholds. APCM also covers patients with a single chronic condition at its first tier. A patient can be enrolled in CCM or APCM in a given month, but not both — many practices run both programs across different segments of their panel.
Ready to improve care for your complex patients?
See how Hoss Care CCM can help you deliver better outcomes while generating new revenue.