CCM is for patients that:

• Are expected to last at least 12 months (or until death),
• Place the patient at significant risk of death, hospitalization, acute exacerbation/decompensation, or functional decline,
• Require an ongoing, comprehensive care plan and regular management between office visits.

Think of CCM as the “multi‑condition” version of PCM, which applies to a single serious chronic condition.

📋 CCM RequirementsTo bill CCM under CPT codes 99490, 99439, 99491, 99437, 99487, 99489, the following elements must be met:

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1) 🗓️ Initiating Visit

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A face-to-face initiating visit (AWV, IPPE, or E/M) is required for new patients or those not seen within the past 12 months.
“We require an initiating visit before you start CCM services.” (CMS, MLN909188)

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2) 🩺 Patient Eligibility

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The patient has two or more chronic conditions expected to last 12 months or more (or until death) and that pose a significant risk of exacerbation or decline.
“CCM is managing a patient’s multiple (2 or more) chronic conditions expected to last at least 12 months … at significant risk of death, acute exacerbation or decompensation, or functional decline.” (CMS, MLN909188)

3) ⏱️ Time Thresholds

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Count per calendar month time spent on CCM activities.

• 99490: First 20 minutes of clinical staff time (under general supervision).
• +99439: Each additional 20 minutes of staff time.
• 99491: First 30 minutes of physician/QHP time (personally performed).
• +99437: Each additional 30 minutes of physician/QHP time.
• 99487: First 60 minutes of complex CCM (moderate/high MDM).
• +99489: Each additional 30 minutes of complex CCM.
  “You can’t bill for CCM services of less than the required 20 or 30 minutes per calendar month.” (CMS)
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4) 🧭 Comprehensive Care Plan

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Create, revise, and monitor a patient-centered electronic care plan that typically includes: problem list, prognosis, measurable goals, symptom management, planned interventions, medication management, and caregiver input. (Paraphrased to avoid AMA descriptor text; align with CMS MLN elements.)

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5) 💊 Medication Management

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Perform medication reconciliation and oversight, address interactions/side effects, and support adherence through education and follow-up. (Paraphrased; no AMA text quoted.)

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6) 🔄 Communication & Coordination

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Maintain ongoing communication and care coordination with the patient/family/caregiver and other treating professionals. Many programs include at least one two-way touchpoint each month as a best practice. CMS MLN materials also emphasize 24/7 access, patient/caregiver engagement, and multiple modalities (phone, secure portal, email).
Acceptable forms of communication include:
• Phone calls with patient/caregiver
• Video or telehealth check-ins
• Secure portal messaging with response
• In-person contact outside of E/M visits
• Provider-to-provider communication (documented and relayed to patient)

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7) 🚫 Billing Restrictions

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Only one practitioner can bill CCM for a patient per calendar month.
CCM can’t be billed concurrently with PCM by the same practitioner for the same patient in the same month.
“Only 1 practitioner can provide and bill CCM services during a calendar month.” (CMS, MLN909188)

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8) 📅 Frequency

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Bill monthly, as long as time and service elements are met.
“You may provide CCM services monthly, as medically necessary.” (CMS)

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