Chronic Care Management.

Care coordination for patients with chronic conditions

Non-face-to-face care coordination for patients with multiple chronic conditions. Medicare beneficiaries with two or more chronic conditions expected to last at least 12 months.

CCM program data flow — complete pipelineCCM program data flow — stage 1CCM program data flow — stage 2CCM program data flow — stage 3

874

Integration Guides

7

Monitoring Types

5

Qualifying Conditions

Quick Answer

What is Chronic Care Management and how does CCN Health deliver it?

Chronic Care Management (CCM) is a Medicare-reimbursable program that non-face-to-face care coordination for patients with multiple chronic conditions CCN Health provides turnkey CCM services including device provisioning, EHR integration, clinical monitoring, and billing — typically launching within 2–4 weeks.

Billing

CCM reimbursement.

Non-face-to-face care coordination for patients with multiple chronic conditions

CPT CodeServiceReimbursement
99490CCM Services~$62/mo
99491Complex CCM~$86/mo
99439Additional 20 min~$47/mo
Monthly potential per patient~$80–130

Clinical

Qualifying conditions.

01

Hypertension + Diabetes

I10 + E11.x

02

Heart Failure + CKD

I50.x + N18.x

03

COPD + Heart Failure

J44.x + I50.x

04

Diabetes + CKD

E11.x + N18.x

05

Hypertension + CKD

I10 + N18.x

Patient Criteria

Medicare beneficiaries with two or more chronic conditions expected to last at least 12 months. Conditions must place the patient at significant risk of death, acute exacerbation, or functional decline.

Advantages

Key benefits.

Billable monthly without device requirement

Care plan development and revision

Medication reconciliation and management

Coordination across multiple providers

Questions?

Want to learn more about CCM for your practice?

Our team can answer your questions and show you how it works with your current workflow.

FAQ

Common CCM questions.

CCM is a Medicare program that reimburses providers for non-face-to-face care coordination for patients with two or more chronic conditions, billed under CPT codes 99490, 99439, and 99491.

CCN Health bills the following CCM CPT codes: 99490 (CCM Services), 99491 (Complex CCM), 99439 (Additional 20 min). Typical monthly revenue per patient is ~$80–130.

Common qualifying conditions for CCM include Hypertension + Diabetes, Heart Failure + CKD, COPD + Heart Failure, Diabetes + CKD, Hypertension + CKD. Medicare beneficiaries with two or more chronic conditions expected to last at least 12 months. Conditions must place the patient at significant risk of death, acute exacerbation, or functional decline.

Most facilities are fully operational within 2–4 weeks. CCN Health handles device provisioning, EHR integration setup, staff training, and ongoing clinical support for CCM programs.

Integration Guides

CCM articles.

874 articles

How CCN Health Helps

From setup to scale.

01

Discovery & Setup

We learn your workflows, EHR configuration, and patient population — then configure CCN’s platform to match.

02

Launch & Monitor

Devices ship directly to patients, data flows into your EHR automatically, and our clinical team monitors around the clock.

03

Scale & Optimize

Expand enrollment, add new programs, and let AI-driven insights continuously improve outcomes and reimbursement.

Ready to Get Started?

Let’s design your CCM program.

Book a short discovery call and we’ll map out a program tailored to your workflows, EHR, and patient population.

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