How to Launch a CCM Program at Your Practice (Without Overwhelming Your Team)

Step 1: Identify Which Patients Qualify

The existing eligibility criteria are as follows: Two or more chronic conditions expected to last at least 12 months that require continuous medical care and cannot be easily cured.

Common qualifying conditions include diabetes, hypertension, chronic kidney disease, cardiovascular disease, Alzheimer’s disease, cancer, arthritis, asthma, atrial fibrillation, depression, and other chronic conditions. Before billing CCM, obtain the patient’s written or verbal consent and document it in the medical record. CMS requires an initiating visit for new patients or patients who have not been seen within the previous year. That visit can be an E/M visit, Annual Wellness Visit, or Initial Preventive Physical Exam, and CCM must be discussed during the visit.

Step 2: Understand What a Compliant Month Requires

Within a calendar month, a registered nurse or care coordinator/medical assistant working under provider supervision spends at least 20 minutes of non-face-to-face care work on a qualifying patient. Those activities can include patient outreach calls, medication review, care plan updates, or provider coordination.

CPT Codes

At 20 minutes of documented time, the month is compliant and billable under CPT 99490. For patients with complex needs requiring higher-intensity decision-making, the monthly minimum is 60 minutes, billed under CPT 99487. Each additional 30 minutes of complex care beyond the 99487 threshold bills under CPT 99489.

Step 3: Build the Documentation Workflow Before Enrolling Patients

A common mistake in first-time CCM programs is enrolling patients too quickly and building the documentation workflow later.

Two workflow elements need to be in place before the first patient is enrolled:

1. Building the Care Plan: CMS requires a patient-specific care plan that addresses the current chronic conditions, medications, and care management goals, and is kept current as the patient’s care evolves.
2. Capturing and Documenting Time: Every qualifying minute of CCM care work needs to be documented for the correct patient and calendar month.

Step 4: Start With 50 Patients, Not 500

Starting with a cohort of approximately 50 patients gives your care team space to build the workflow and reach consistent compliance before patient volume increases. Choose patients with well-documented conditions, established care relationships, and reliable contact information.

In month one, plan to track just one thing: How many patients reached 20 minutes of documented care work and how many did not. That number tells the team where their workflow needs adjustment before the program expands.

Step 5: Know What Good Looks Like at 90 Days

By month three, a well-run first cohort typically produces a compliance rate above 70%, depending on the patient mix and your team’s workflow consistency. That number is the benchmark worth tracking and the one that makes the case for expanding to the next cohort.

When your care team is reaching compliant months without end-of-month documentation scrambles and time is being documented consistently, the program is ready to scale.