Chronic Care Management (CCM) Programs: Medicare CPT 99490, 99439, 99491 & 99487 Rules, Consent, Documentation Template, and Payer Coverage

Chronic Care Management (CCM) programs are structured, non-face-to-face longitudinal care coordination programs established by the Centers for Medicare & Medicaid Services (CMS) under the Medicare Physician Fee Schedule (MPFS) to reimburse physicians and non-physician practitioners for managing patients with two or more serious chronic conditions between office visits. Governed by CMS MLN guidance (Chronic Care Management Services, MLN909188) and 42 CFR § 410.26(b)(5), CCM programs bridge episodic outpatient E/M office visits and continuous patient remote monitoring (RPM) by funding monthly clinical staff and physician care-plan oversight, medication reconciliation, 24/7 urgent access, and care transitions.

What Is Chronic Care Management (CCM) in Healthcare?

The regulatory definition of Chronic Care Management under Medicare Part B encompasses non-face-to-face care coordination services provided over a calendar month to a patient who meets three statutory clinical eligibility criteria:

1. Multiple Chronic Conditions: The patient has two or more (`≥ 2`) chronic continuous or episodic health conditions (such as hypertension, type 2 diabetes mellitus, heart failure, chronic obstructive pulmonary disease, chronic kidney disease, depression, or osteoarthritis).
2. Expected Duration: The chronic conditions are expected to last at least 12 months, or until the death of the patient.
3. Clinical Risk Threshold: The chronic conditions place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline.

Only one practitioner (a physician, nurse practitioner, physician assistant, clinical nurse specialist, or certified nurse-midwife—or a Rural Health Clinic [RHC] / Federally Qualified Health Center [FQHC] billing HCPCS G0511) may bill CCM for a given beneficiary during a single calendar month.

Does Medicare Cover Chronic Care Management? CPT 99490, 99439, 99491, and 99487 Explained

Yes. Medicare Part B covers Chronic Care Management across two clinical complexity tiers—Non-Complex CCM and Complex CCM—further subdivided by whether the monthly time is performed by clinical staff under general supervision (42 CFR § 410.26(b)(5), meaning the supervising physician or NPP does not need to be physically in the office suite while an RN, LPN, or MA performs telephone care coordination) or personally by the billing physician/QHP:

CPT / HCPCS Code	CCM Service Category	Who Performs the Time?	Minimum Monthly Time Threshold	Medical Decision Making (MDM) & MUE Rules
CPT 99490	Non-Complex CCM (Base Code)	Clinical staff directed by a physician/QHP (General Supervision)	≥ 20 minutes per calendar month	Routine care plan oversight; billed once per calendar month
CPT 99439	Non-Complex CCM (Add-On to 99490)	Clinical staff directed by a physician/QHP	Each additional 20 minutes (40+ min = 1 unit; 60+ min = 2 units)	Capped at 2 units per patient per calendar month
CPT 99491	Physician/QHP Personal Non-Complex CCM (Base)	Personally by a physician or QHP (staff time excluded)	≥ 30 minutes per calendar month	Cannot be billed in the same month as 99490 or Complex CCM
CPT 99437	Physician/QHP Personal CCM (Add-On to 99491)	Personally by a physician or QHP	Each additional 30 minutes (60+ min = 1 unit; 90+ min = 2 units)	Capped at 2 units per patient per calendar month
CPT 99487	Complex CCM (Base Code)	Clinical staff directed by a physician/QHP	≥ 60 minutes per calendar month	Requires establishment/substantial revision of care plan + moderate or high MDM
CPT 99489	Complex CCM (Add-On to 99487)	Clinical staff directed by a physician/QHP	Each additional 30 minutes beyond the initial 60 minutes (90+ min)	Requires documented moderate-to-high complexity MDM by billing clinician
HCPCS G0506	Comprehensive Assessment & Care Plan Add-On	Personally by billing practitioner at the CCM Initiating Visit	Extensive face-to-face assessment & care planning beyond usual E/M	Billed once at program initiation alongside the initiating E/M or AWV
HCPCS G0511	RHC & FQHC General Care Management	RHC/FQHC clinical staff or practitioner	≥ 20 minutes per calendar month	Dedicated composite payment code for Rural Health Clinics and FQHCs

Does Medicaid or Commercial Insurance (Such as UnitedHealthcare) Cover Chronic Care Management?

Coverage outside traditional fee-for-service Medicare Part B depends on the payer category:

• Medicare Advantage (Part C) Plans (Including UnitedHealthcare, Humana, and Aetna MA): Under 42 CFR § 422.101, Medicare Advantage organizations must cover all original Medicare Part A and Part B benefits, including Chronic Care Management codes (99490, 99439, 99491, 99487, 99489). Many Medicare Advantage plans waive the 20% Part B coinsurance for in-network primary care CCM to improve Medicare Advantage Star Ratings HEDIS medication adherence and chronic disease control measures.
• Medicaid State Plans and Dual-Eligible Beneficiaries: For dual-eligible patients (enrolled in both Medicare Part B and state Medicaid), Medicare acts as the primary payer (paying 80% of the MPFS allowed amount after the Part B deductible), and state Medicaid typically crosses over to cover the remaining 20% patient coinsurance under QMB (Qualified Medicare Beneficiary) cost-sharing rules. For Medicaid-only beneficiaries, coverage is determined state by state: a majority of state Medicaid fee schedules (and Medicaid Managed Care Organizations) reimburse CPT 99490 or fund dedicated state Health Home / primary care case management per-member-per-month (PMPM) equivalents.
• Commercial Payers (UnitedHealthcare Commercial, Cigna, BCBS): Many commercial health plans recognize CPT 99490–99491 on their professional fee schedules or incorporate CCM into value-based primary care capitation/care-management PMPM contracts, though commercial member cost-sharing (high-deductible health plan applicability) must be verified during patient enrollment.

Mandatory CCM Enrollment, Patient Consent, and Operational Requirements

Before a clinic can submit its first monthly CCM claim, CMS requires strict compliance with five operational prerequisites:

1. Initiating Visit for New Patients: For new patients or patients not seen by the billing practitioner within the preceding 12 months, the practitioner must first conduct a face-to-face initiating visit—such as a comprehensive E/M visit (Levels 2–5), an Annual Wellness Visit (AWV, G0438/G0439), an Initial Preventive Physical Examination (IPPE, G0402), or a Transitional Care Management (TCM, 99495/99496) visit—and discuss CCM during that encounter.
2. Advance Informed Patient Consent: Prior to starting CCM services, the practice must obtain and document verbal or written patient consent in the EHR. The consent disclosure must explicitly inform the patient: (a) what CCM services entail, (b) that only one practitioner may furnish and bill CCM for them per calendar month, (c) that standard Medicare Part B cost-sharing (annual deductible and 20% coinsurance) applies in the absence of supplemental/Medigap or Medicaid coverage, and (d) that the patient has the right to stop (revoke) CCM services at any time (effective at the end of the current calendar month).
3. 24/7 Access and Continuity of Care: The practice must provide the patient with 24-hour-a-day, 7-day-a-week access to physicians, QHPs, or clinical staff to address urgent chronic care needs regardless of time of day or day of week, alongside scheduled appointments with a designated primary care team member.
4. ONC-Certified EHR Recording: Structured recording of patient demographics, problems, medications, and medication allergies must be maintained in an ONC-certified EHR.
5. Patient-Centered Comprehensive Care Plan: A comprehensive electronic care plan addressing all health issues (with focus on the chronic conditions) must be established, shared with the patient/caregiver in physical or portal form, and made available electronically to all care team members.

Chronic Care Management Documentation Template & Audit Examples

During Medicare Administrative Contractor (MAC) and OIG post-payment audits, the two leading causes of CCM recoupment are incomplete care plans and unverified monthly time logs. A compliant Chronic Care Management documentation template in the EHR contains two distinct artifacts:

Part A: Comprehensive Electronic Care Plan Template

• Active Chronic Problem List & Prognosis: ICD-10-CM coded diagnoses (e.g., I10 Essential Hypertension; E11.22 Type 2 Diabetes Mellitus with Diabetic CKD; N18.31 CKD Stage 3a) with baseline status and 12-month prognosis.
• Measurable Treatment Goals & Target Metrics: Patient-specific clinical targets with target dates (e.g., “Maintain home seated blood pressure < 130/80 mmHg over next 90 days; reduce HbA1c from 8.4% to < 7.2% by 6-month lab recheck”).
• Symptom Management & Action Plan: Early warning thresholds and exacerbation instructions (e.g., weight gain > 3 lbs in 24 hours or > 5 lbs in 7 days for CHF; hypoglycemia protocol for blood glucose < 70 mg/dL).
• Planned Interventions & Specialist Coordination: Scheduled lab panels, referrals (nephrology, ophthalmology retinal exam), and community/social support services (transportation, nutrition counseling).
• Complete Medication Reconciliation & Adherence Assessment: Dose, frequency, prescribing clinician, pharmacy contact, and assessment of financial or side-effect barriers to adherence.

Part B: Monthly CCM Time-Log Documentation Example

• 2026-11-04 (08 min — RN Care Coordinator, J. Smith, RN): Completed monthly structured outreach call with patient. Reviewed home glucose log (fasting range 118–142 mg/dL) and reconciled lisinopril 20 mg daily + empagliflozin 10 mg daily against retail pharmacy refill history. Confirmed zero hypoglycemic episodes.
• 2026-11-12 (06 min — RN Care Coordinator, J. Smith, RN): Received specialist consultation note from Nephrology; updated EHR medication list to reflect potassium-sparing dietary guidance and forwarded recent BMP/eGFR lab results to nephrologist’s portal.
• 2026-11-21 (09 min — RN Care Coordinator, J. Smith, RN): Follow-up telephone check-in regarding mild lower-extremity edema; reviewed low-sodium dietary action plan from care plan, scheduled in-person follow-up with PCP for 2026-11-24, and sent updated care plan summary to patient portal.
• Total Monthly Non-Face-to-Face Clinical Staff Time: 23 minutes → Eligible for CPT 99490 (1 unit).

Frequently Asked Questions

Can a practice bill Chronic Care Management (99490) and Remote Physiologic Monitoring (99457) in the same month?

Yes. CMS explicitly permits concurrent billing of CCM (99490/99439/99491/99487) and Remote Physiologic Monitoring treatment management (CPT 99457 and CPT 99458) for the same patient in the same calendar month, provided no clinical staff or practitioner minute is counted twice. A practice billing both 99490 (20 minutes) and 99457 (20 minutes) must document at least 40 total distinct, non-overlapping minutes of care management and RPM review.

Which services cannot be billed in the same calendar month as CCM?

Under CMS MPFS bundling rules, a practitioner cannot bill CCM during the same service period as Transitional Care Management (TCM, 99495–99496, during the 30-day post-discharge window), Home Health Care Supervision (G0181), Hospice Care Supervision (G0182), or certain End-Stage Renal Disease (ESRD) monthly capitation codes (90951–90970).

Do you have to obtain a new CCM consent form every year?

No. Once advance verbal or written patient consent is obtained and documented in the EHR, it remains valid indefinitely unless the patient revokes consent or transfers their CCM enrollment to a different billing practice.