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• Patient consent: Obtain and document the patient's consent to receive CCM services.
• Comprehensive care plan: Develop and document a comprehensive, patient-centered care plan that includes:
  • Problem list
  • Expected Outcomes and Prognosis
  • Measurable treatment goals
  • Symptom management
  • Planned interventions
  • Medication management
  • Community/social services ordered
  • A schedule for periodic review and, when applicable, revision of the care plan
• Time spent on CCM services: Document the time spent on non-face-to-face care management services for each calendar month, including:
  • Care coordination with other healthcare providers
  • Reviewing medical records, test results, and care plan updates
  • Communication with the patient and their caregivers
  • Medication management and reconciliation
  • Providing patient education and support

•  CPT 99490: At least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month.
  • Documentation of time spent on CCM services is required.
• CPT 99487: Complex CCM that requires at least 60 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month.
  • Documentation of time spent on CCM services is required.
  • Patients must have multiple (typically three or more) chronic conditions that require a higher level of care management.
• CPT 99489: Each additional 30 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month.
  • Can be billed in conjunction with CPT 99487 when more than 60 minutes of complex CCM services are provided.
  • Documentation of time spent on CCM services is required.

Frequently asked questions (FAQs) related to Chronic Care Management (CCM) services. Here they are: 

Q1: What is Chronic Care Management (CCM)?

A1: Chronic Care Management (CCM) is a healthcare service that provides ongoing care coordination, management, and support for patients with two or more chronic conditions. It aims to improve patient outcomes, reduce healthcare costs, and enhance the patient-provider relationship.

Q2: Who is eligible for CCM services?

A2: Patients with two or more chronic conditions expected to last at least 12 months or until death are eligible for CCM services. These conditions must place the patient at significant risk of death, acute exacerbation, or functional decline.

Q3: What are the core components of CCM services?

A3: The core components of CCM services include care planning, care coordination, medication management, patient and caregiver engagement, and access to care management services.

Q4: How does billing work for CCM services?

A4: Billing for CCM services is based on specific CPT codes established by CMS. The primary code for CCM services is 99490. Providers can bill for CCM services once per calendar month, and documentation must support the services provided.

Q5: Can CCM services be provided alongside other care management services, like Remote Patient Monitoring (RPM)?

A5: Yes, CCM services can be provided in conjunction with other care management services like RPM. Combining CCM and RPM services can lead to better patient outcomes and more efficient healthcare delivery.

Q6: What are the benefits of CCM for patients and providers?

A6: The benefits of CCM for patients include improved health outcomes, better management of chronic conditions, increased access to care, and enhanced patient engagement. Providers can benefit from more efficient care delivery, better patient compliance, and a potential new revenue stream.

Q7: How can providers ensure patient privacy and security in CCM services?

A7: To maintain patient privacy and security, providers must use HIPAA-compliant communication methods and systems. They should also implement strong data encryption and access controls to protect patient information.

Q8: Are there any limitations or challenges with CCM services?

A8: Some limitations and challenges with CCM services include the need for ongoing patient engagement, patient education, and support, as well as potential barriers related to technology and communication. Additionally, adequate staffing and resources are necessary to provide effective CCM services.