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.

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Illustration comparing declining fee-for-service reimbursement against rising CCM and RPM revenue, showing how care management programs protect Medicare practice income in 2026.

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