Chronic Care Management

CCM: Consistency That Drives Better Care

  • Earn monthly reimbursements per patient

  • Improve outcomes with proactive care coordination

  • Offload your team with our white-labeled solution

CCM

What Is Chronic Care Management (CCM)?

Chronic Care Management (CCM) is a Medicare program that supports patients with two or more chronic conditions. CCM helps healthcare providers deliver ongoing, coordinated care between office visits—improving patient outcomes and increasing revenue for your practice.
  • Who is CCM for? Patients with two or more chronic conditions expected to last at least 12 months (such as diabetes, heart disease, or COPD) are eligible for CCM services.
  • Why is it great for patients?  Patients receive consistent, personalized follow-up and support between doctor visits. This leads to better medication adherence, fewer hospitalizations, and improved overall outcomes.
  • Why is it great for practices? Practices strengthen patient relationships, improve care continuity, and are reimbursed for work they already do—such as care coordination, follow-ups, and outreach.
How It Works (In Plain English)
Your patient has two or more chronic conditions—things like diabetes, hypertension, or arthritis.
Each month, your staff spends 20+ minutes coordinating their care: phone check-ins, medication refills, scheduling, follow-ups.

Our platform logs the time, tracks every task, and makes sure it's audit-proof. At the end of the month, you bill Medicare and get paid.

No device needed. Just your team, the patient, and our software keeping it all organized.
Vitals You Can Monitor
Blood Pressure Monitor
Thermometer
Weight Scale
Caregiver app
Clinical Surveys
GCMs
Glucose Monitor
Pulse Oximeter
Sleep Analyzer
Smart Pillbox
See Devices

Chronic Care Management Codes

CPT 99439

(

~$45

)

Additional 20 minutes – non‑complex (add‑on)

Additional 20 Minutes of Non‑Complex CCM

This add-on code is for each extra 20‑minute block (beyond the initial 20 under 99490) of non-complex CCM services in the same month.

CPT 99487

(

~$133

)

60‑minute clinical staff time – complex

Initial 60 Minutes of Complex CCM

This code covers at least 60 minutes of chronic care management for patients with complex conditions requiring moderate-to-high medical decision-making, provided by clinical staff under physician or advanced practitioner supervision in a calendar month.

CPT 99489

(

~$47

)

Additional 30 minutes – complex (add‑on)

Additional 30 Minutes of Complex CCM

This add-on code covers each extra 30‑minute increment of complex CCM services beyond the initial 60 in the same calendar month.

CPT 99490

(

~$60

)

20‑minute clinical staff time – non‑complex

Initial 20 Minutes of Non‑Complex CCM

This is billed when clinical staff, under physician or advanced practitioner supervision, provides at least 20 minutes of non-complex chronic care management services in a calendar month.

Increase your CCM revenue today

CPT 99439
(
~$45
)
Additional 20 minutes – non‑complex (add‑on)
This add-on code is for each extra 20‑minute block (beyond the initial 20 under 99490) of non-complex CCM services in the same month.
CPT 99487
(
~$133
)
60‑minute clinical staff time – complex
This code covers at least 60 minutes of chronic care management for patients with complex conditions requiring moderate-to-high medical decision-making, provided by clinical staff under physician or advanced practitioner supervision in a calendar month.
CPT 99489
(
~$47
)
Additional 30 minutes – complex (add‑on)
This add-on code covers each extra 30‑minute increment of complex CCM services beyond the initial 60 in the same calendar month.
CPT 99490
(
~$60
)
20‑minute clinical staff time – non‑complex
This is billed when clinical staff, under physician or advanced practitioner supervision, provides at least 20 minutes of non-complex chronic care management services in a calendar month.
A Nurse taking care of a patient

Why Choose CCN Health?

Instant EHR Integration

Automatically sync patient data directly into your existing workflow—no manual entry required.

Transparent Billing Guidance

Know exactly what CPT codes apply, why they apply, and how to maximize your reimbursements.

Rapid Onboarding

Go from discovery to billing within a single week. No delays, no hassles.

Zero Risk & No Cost

All devices, training, and integration are completely free. You pay nothing upfront.

🚀 6-Step “Quick-Launch” Framework
Understanding the process
01

Discovery Call (Just 20 minutes)

Simply pick a convenient time to meet virtually with your dedicated onboarding specialist. We'll quickly analyze your current workflow and EHR setup, identify clear revenue opportunities, and walk you through potential billing scenarios step-by-step.

02

Sign HIPAA BAA & e-Agreements

We make compliance simple. Quickly e-sign our standard Business Associate Agreement (BAA) and delegation paperwork, and we’ll instantly provision your own branded, secure portal and establish compliant, EHR-integrated data channels.

03

Receive Free Starter Devices

You'll receive fully-configured, pre-paired test devices—like blood pressure cuffs, scales, pulse oximeters, spirometers, or Bluetooth trackers—depending on your chosen program. Devices ship fast, completely free, and require zero setup.

04

Fast & Simple Patient Import

Identify a small group of pilot patients—we’ll automatically generate eligibility reports to help. Importing patients from your existing EHR into our platform is seamless, and capturing digital consent via text or email takes just seconds.

05

Workflow Customization & Staff Training

Join one short, tailored training session (45 minutes max) where your team learns intuitive workflows, customizable alerts, and easy task routing. We ensure everything aligns smoothly with your existing internal processes and provide continuous support.

06

Start Billing With Confidence

Begin delivering care immediately using your familiar workflows. Easily approve care interactions within your EHR, clearly see which CPT codes are billable, and understand exactly why each patient qualifies or what simple steps you need to take to ensure eligibility.

How to Use CCN Health Software for a Month of Chronic Care Management (CCM)

Throughout the entire process, our software automatically tracks time and captures notes—you can manually add additional notes and time entries at any point.

1. Check Patient Goals

2. Update Chronic Conditions

  • Ensure each chronic condition has current information.

    • Examples: Medications, Symptoms, Treatments, Specialists, Next Steps

  • Automatically consolidate recent EHR updates with your CCM Care Plan.
  • Keeps the patient's clinical information accurate and audit-ready.

3. Patient Interaction

  • Clinical screenings and surveys:  PHQ-9, GAD-7, Falls Risk, etc.

4. Doctor Review & Finalization

  • Doctor (or authorized clinician) reviews the full month’s clinical notes.

  • Signs off and finalizes the CCM Care Plan:

    • Finalized doctor's note included.
    • All clinical notes and patient interactions summarized.


5. Generate Audit-ready Report

  • One-click export of the completed month's CCM report.
  • Fully compliant, detailed, and ready for CMS audits.
  • Signs off and finalizes the CCM Care Plan:

    • Finalized doctor's note included
    • All clinical notes and patient interactions summarized.



Ongoing: Automatic Time Tracking & Notes

  • Throughout the entire month:
    • Auto-tracked monitoring time
    • Easily add notes, manual time entries, or adjustments
    • Always compliant and transparent
Ready to Start?
Schedule your quick, no-obligation discovery call today—and start billing CCM, RPM, RTM, PCM, or BHI within your first 30 days.