Chronic Care Management (CCM): A Smarter Way to Support Patients and Strengthen Your Practice

Chronic conditions affect more than six in ten Medicare beneficiaries, and for many practices, managing these patients means juggling complex care plans, frequent follow-ups, medication adherence, and ongoing coordination — all while protecting already-thin margins.

This is where Chronic Care Management (CCM) plays a critical role.

CCM is a Medicare-approved care model designed to support patients living with multiple chronic conditions while enabling practices to deliver better outcomes, improve patient engagement, and generate sustainable monthly revenue. For practices already offering Remote Patient Monitoring (RPM), CCM is a natural and highly complementary next step.

At Telecare-USA, we work with practices nationwide to implement RPM and CCM programs that are compliant, efficient, and clinically meaningful — without adding administrative burden.

Let’s break down what CCM is, who qualifies, how to bill, and why adoption continues to grow.

What Is Chronic Care Management (CCM)?

Chronic Care Management is a Medicare Part B service that reimburses practices for non-face-to-face care coordination provided to patients with ongoing health needs.

CCM focuses on:

• Proactive care planning
• Regular patient communication
• Medication management and adherence
• Coordination between providers and care teams
• Preventing avoidable hospitalizations and complications

Unlike episodic care, CCM is continuous, allowing care teams to support patients between office visits — where many clinical issues actually arise.

Who Qualifies for CCM?

Under Medicare guidelines, a patient qualifies for CCM if they:

• Have two or more chronic conditions
• Conditions are expected to last at least 12 months (or until death)
• Conditions place the patient at significant risk of death, acute exacerbation, or functional decline

Common qualifying conditions include:

• Hypertension
• Diabetes
• Heart failure
• COPD
• Asthma
• Arthritis
• Depression
• Chronic kidney disease

Patients must also:

• Provide verbal or written consent
• Have a comprehensive care plan on file
• Be enrolled with one billing provider for CCM services

What Does CCM Actually Include?

CCM services go far beyond a quick monthly check-in. Medicare requires that care teams actively support patients throughout the month.

Key CCM activities include:

• Creating and updating a personalized care plan
• Medication reconciliation and adherence support
• Coordinating care across specialists, hospitals, and pharmacies
• Responding to patient questions or concerns outside of office visits
• Monitoring symptoms and escalating issues when necessary

For billing purposes, a minimum of 20 minutes per month of clinical staff time (directed by a provider) is required for standard CCM services.

Why CCM Is Growing Rapidly

CCM adoption continues to accelerate — and for good reason.

1. Improved Patient Outcomes

Regular engagement leads to:

• Better medication adherence
• Earlier identification of clinical issues
• Reduced ER visits and hospitalizations
• Higher patient satisfaction

Patients feel supported, not forgotten between appointments.

2. Predictable Monthly Revenue

CCM provides recurring, per-patient reimbursement, creating stable revenue that is not dependent on in-office visits. For practices managing large Medicare populations, this can significantly impact financial sustainability.

3. Supports Value-Based Care Goals

CCM aligns directly with quality initiatives, population health management, and preventive care strategies emphasized by Centers for Medicare & Medicaid Services.

CCM CPT Codes: How Chronic Care Management Is Billed

Medicare reimburses Chronic Care Management through a set of monthly CPT codes designed to reflect the level of clinical support and time required to manage patients with multiple chronic conditions.

These services are governed by Centers for Medicare & Medicaid Services and billed under Medicare Part B.

Core CCM CPT Codes

99490 – Standard CCM

• At least 20 minutes per month of clinical staff time
• Directed by a physician or qualified healthcare professional
• Non-face-to-face care coordination
• Most commonly used CCM code

99439 – Additional CCM Time

• Each additional 20 minutes per month
• Billed in conjunction with 99490
• Used for higher-acuity patients requiring more support

Complex CCM Codes (Higher Acuity Patients)

99487 – Complex CCM

• At least 60 minutes per month
• Patients with more complex medical decision-making
• Requires substantial care coordination

99489 – Additional Complex CCM Time

• Each additional 30 minutes per month
• Billed with 99487 when time thresholds are exceeded

What Medicare Requires to Bill CCM

To bill CCM compliantly, practices must meet all CMS requirements — documentation and workflow matter just as much as time tracking.

Required Elements Include:

Patient Eligibility

• Two or more chronic conditions
• Expected to last at least 12 months
• Conditions place the patient at significant health risk

Patient Consent

• Verbal or written consent (documented in the chart)
• Patient must be informed of:
• Monthly billing
• Copays/coinsurance (unless waived per policy)
• Ability to revoke consent at any time

Comprehensive Care Plan

• Problem list
• Medication list
• Measurable treatment goals
• Coordination with other providers
• Must be accessible to the care team and patient

Time Documentation

• Time must be:
• Tracked monthly
• Non-face-to-face
• Clinical staff time under provider direction
• Only one provider may bill CCM for a patient per month

Who Can Perform CCM Services?

CCM time may be performed by:

• Clinical staff (RNs, LPNs, MAs, care coordinators)
• Under the general supervision of a billing provider

This flexibility allows practices to deliver CCM efficiently without requiring physician involvement for every interaction — while still remaining compliant.

How CCM Is Billed

• CCM is billed once per calendar month
• Claims are submitted at the end of the month
• Time cannot be carried over from prior months
• CCM may be billed alongside other services, including RPM, when requirements for each are met

Importantly, CCM does not require a patient visit in the billing month, making it an ideal program for supporting patients between appointments.

CCM and RPM: Billing Together

CCM and Remote Patient Monitoring may be billed together when:

• Each service meets its own documentation and time requirements
• CCM time and RPM time are tracked separately
• Services are not duplicative

RPM provides physiologic data; CCM turns that data into coordinated, actionable care — a model Medicare actively supports.

CCM + RPM: A Powerful Combination

For practices already offering RPM, CCM enhances and extends the value of monitoring programs.

RPM focuses on physiologic data — blood pressure, glucose, weight, oxygen saturation.
CCM focuses on the whole patient — education, adherence, care coordination, and follow-up.

Together, they create:

• More complete documentation
• Better patient engagement
• Stronger clinical oversight
• Optimized reimbursement opportunities

RPM data often informs CCM care decisions, while CCM outreach ensures RPM insights turn into action.

Is CCM Right for Your Practice?

If your practice:

• Serves Medicare patients with multiple chronic conditions
• Wants to improve outcomes beyond office visits
• Is looking for predictable, compliant revenue growth
• Already offers (or is considering) RPM

Then CCM may be one of the most impactful programs you can implement.

Interested in Adding CCM to Your Care Model?

Telecare-USA works directly with practices to design CCM programs that fit seamlessly into existing workflows — while improving patient care and long-term sustainability.

Contact us today to learn how CCM can strengthen your practice and support healthier patients year-round. Use the button below to connect with our team. 

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