Chronic Care Management for Providers

Chronic Care Management (CCM) is a care coordination program for patients with two or more chronic conditions that are expected to last at least 12 months and place them at significant risk of health decline. It includes non-face-to-face services like care planning, medication management, and health coaching — all documented and billable under specific CPT codes.

Patients qualify for CCM if they have at least two chronic conditions that are expected to last a year or more (or until death) and significantly increase their risk of hospitalization, functional decline, or serious health events.

The most commonly used CPT codes for CCM include:

• 99490: 20+ minutes of clinical staff time per month
• 99439: Each additional 20 minutes
• 99491: 30+ minutes of time by a physician or qualified health professional
• 99437: Add-on code for additional time under 99491

Clinii’s platform automates every step of the CCM process — from patient eligibility checks and task tracking to care plan documentation and billing code generation. It integrates directly with your EMR and supports scalable, compliant care coordination.

Yes. Patients can be enrolled in CCM alongside other reimbursable programs like Principal Care Management (PCM) or Annual Wellness Visits (AWV), as long as time and documentation requirements for each program are met.

CCM services are reimbursed by Medicare under specific CPT codes, allowing providers to earn additional revenue for delivering non face-to-face care coordination. By enrolling eligible patients and documenting care activities properly, practices can enhance revenue streams while improving patient outcomes. Accurate time tracking and compliance with CMS guidelines are key to maximizing reimbursements.

There are two different types of CCM: Standard CCM and complex CCM. Standard CCM can be distinguished from complex CCM by the respective CPT code. Complex CCM uses codes 99487 and 99489. Complex CCM patients’ care teams must have a significant establishment or revision of the care plan and typically communicate more with the care team staff in a calendar month.

Physicians (regardless of specialty), advanced practice registered nurses, physician assistants, clinical nurse specialists, certified nurse-midwives, or the provider to which such individual has reassigned their billing rights are eligible to bill Medicare for CCM. Other non-physician practitioners and limited-license practitioners (e.g., clinical psychologists or social workers) and providers not eligible for reimbursement under the Medicare Physician Fee Schedule (e.g., pharmacists) cannot bill for CCM.

Yes. Patients can be enrolled in more than one care program — such as Chronic Care Management (CCM), Principal Care Management (PCM), and Annual Wellness Visits (AWV) — as long as the required documentation and time thresholds are met for each service. Clinii is built to support this layered care delivery model without added operational complexity.