What is chronic care management?

Chronic Care Management (CCM) is defined by the Centers for Medicare and Medicaid Services (CMS) as coordinating care for patients with multiple chronic conditions outside regular office visits. These conditions are expected to last at least 12 months or until the patient passes away.

What are the benefits of chronic care management?

CCM helps practices create personalized care plans, improve adherence to care guidelines, streamline documentation, and support a more efficient billing workflow. The goal is to improve outcomes, reduce complications, and stay aligned with CMS requirements.

How does chronic care management work?

CCM typically includes patient enrollment, creation of a care plan, ongoing monthly care coordination and patient communication, and accurate documentation for billing and reimbursement.

What services are included in chronic care management?

CCM services can include identifying chronic conditions, developing care plans, coordinating referrals, reviewing results, medication support, documenting monthly communication time, and recording billable actions for compliance.

What are Chronic Care Management CPT codes?

CCM CPT codes are billing codes used to report chronic care management services. Common codes can include 99490, 99439, 99487, 99489, 99491, and related codes, depending on the service level and time.

How do Chronic Care Management CPT codes work?

Practices use CCM codes to bill for specific care coordination services based on eligibility, documented activities, and time thresholds. Proper documentation supports accurate reimbursement and transparency for the care delivered.

CMS Publishes 2026 Final Rule on Nov. 1

Mario Erlach
November 4, 2025

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Major 2026 Updates to RPM, CCM, BHI, and APCM

Remote Patient Monitoring (RPM)

For Calendar Year (CY) 2026, CMS finalized important updates to the Remote Physiologic Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) code families to reflect evolving technology use and billing flexibility.

Two new RPM CPT codes were introduced: 99445 and 99470, both designed for cases involving less than 16 days of data transmission within a 30-day period and less than 20 minutes of interactive communication per month. These codes recognize real-world patient adherence patterns and fill a documentation gap between continuous and short-term monitoring.

In addition, CMS updated descriptors for CPT 99454 to specify the minimum number of days of data transmission required per 30-day billing cycle. The new framework better differentiates between full and partial compliance monitoring. CMS expects these codes to be resurveyed once utilization data becomes available, with full review scheduled for 2028.

On the RTM side, four new codes, 98984, 98985, 98979, and 98986, were created for therapeutic monitoring across respiratory, musculoskeletal, and cognitive-behavioral domains. Like RPM, these allow billing for services involving less than 16 days of data and under 20 minutes of patient interaction. All RTM codes will remain on CMS’s New Technology list for three years before full valuation review.

Chronic Care Management (CCM)

The Chronic Care Management framework continues to evolve toward broader care coordination flexibility. CMS reaffirmed that CCM, Transitional Care Management (TCM), and related codes remain eligible for “general supervision”—allowing clinical staff to perform most care coordination tasks without the physician being immediately available. This policy strengthens scalability for practices using team-based, nurse- or MA-driven models of chronic disease management .

CMS also noted its intent to maintain alignment between care management policies in Rural Health Clinics (RHCs), Federally Qualified Health Centers (FQHCs), and Physician Fee Schedule (PFS) settings, ensuring continuity in chronic and preventive care delivery.

Behavioral Health Integration (BHI)

Behavioral Health Integration remains a focus of CMS’s whole-person care strategy. CMS reiterated that CPT 99484 (replacing G0507) continues as the foundational code for general BHI services—covering at least 20 minutes per month of team-based behavioral health coordination, monitoring, and follow-up .

Recognizing the overlap between BHI and advanced primary care, CMS emphasized that behavioral health integration should operate seamlessly within team-based models. It acknowledged that addressing behavioral conditions alongside chronic disease management improves outcomes and patient satisfaction.

Advanced Primary Care Management (APCM)

A major innovation for 2026 is CMS’s proposal of optional add-on codes for Advanced Primary Care Management (APCM) that eliminate the need to track time spent delivering complementary BHI and Collaborative Care Model (CoCM) services. This change reduces documentation burden and encourages integrated behavioral and medical care within primary care settings. By removing the time-based constraints, CMS aims to support a more holistic, proactive model of longitudinal care coordination.

Summary

The 2026 Final Rule represents CMS’s continued shift toward simplified, integrated, and flexible care management. The creation of short-duration RPM and RTM codes acknowledges real-world variations in patient engagement. The new APCM add-on structure links primary and behavioral health more closely, while reaffirmed CCM supervision rules expand team-based chronic care. Collectively, these updates signal a clear move toward a streamlined, tech-enabled, and patient-centered Medicare care management ecosystem.

New 2026 CPT/HCPCS Codes Introduced

RPM: 99445, 99470
RTM: 98984, 98985, 98979, 98986
APCM Add-On Codes: (Unnamed in rule; forthcoming optional BHI/CoCM add-ons)

These changes take effect January 1, 2026, under the CY 2026 Physician Fee Schedule Final Rule.

Mario Erlach

Founder at RPM Logix – Remote Personalized Medicine

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The information provided by RPM Logix is intended for educational purposes only and should not be construed as legal or medical billing advice. While every effort is made to ensure the accuracy and timeliness of the content, RPM Logix makes no representations or warranties of any kind, express or implied, about the completeness, accuracy, reliability, suitability, or availability of the information provided. The coding and billing guidelines, including but not limited to CPT, HCPCS, and ICD codes, are subject to updates and changes by regulatory authorities such as CMS (Centers for Medicare & Medicaid Services) and the AMA (American Medical Association).
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