Chronic Care Management (CCM) is a Medicare Part B benefit that reimburses eligible billing practitioners for non-face-to-face care coordination and management services provided to patients with two or more chronic conditions expected to last at least 12 months or until the patient's death. CMS established separate payment for CCM services in the Calendar Year 2015 Physician Fee Schedule final rule, creating a distinct reimbursement pathway for work that physicians and clinical staff had long performed without compensation.
Patient Eligibility:
A patient qualifies for CCM if they have two or more chronic conditions that place them at significant risk of death, acute exacerbation or decompensation, or functional decline. The conditions must be expected to persist for at least 12 months or until the patient's death. Common qualifying conditions include hypertension, diabetes, chronic kidney disease, chronic obstructive pulmonary disease (COPD), heart failure, depression, arthritis, and hyperlipidemia. CMS does not maintain an exhaustive list of qualifying conditions; the determination rests on clinical judgment within the regulatory definition.
Consent Requirements:
Before a provider can bill CCM for a patient, the patient must give written or verbal consent. The consent must inform the patient that only one practitioner can bill CCM in a given calendar month, that the patient may stop receiving CCM services at any time, and that standard Medicare cost-sharing applies. Consent need only be obtained once for the duration of the care relationship, though it must be documented in the medical record.
Initiating Visit:
New patients, or patients who have not been seen within one year before the start of CCM services, must have an initiating visit. This visit is billed separately. The Annual Wellness Visit (AWV) or an initial preventive physical examination (IPPE, also called the "Welcome to Medicare" visit) may qualify as the initiating visit.
Care Plan Requirements:
Each CCM patient must have a comprehensive, patient-centered care plan that is documented in the medical record. The care plan must include the patient's health conditions and symptoms, medications, a description of required services, the providers responsible for each service, and a plan for coordination with outside providers. The care plan must be revised as needed based on the patient's condition.
Billing Structure:
CCM uses time-based CPT billing codes. Services can be provided by the billing practitioner directly or by clinical staff under the general supervision of the billing practitioner. "General supervision" means the billing practitioner does not need to be physically present during service delivery. Clinical staff can include employees or contracted professionals who perform CCM tasks as an extension of the billing provider, provided they meet applicable state licensure and scope-of-practice requirements.
CCM is divided into non-complex and complex categories:
Non-Complex CCM is for patients whose conditions require care coordination and management without moderate- to high-complexity medical decision-making.
Complex CCM is for patients who require moderate- to high-complexity medical decision-making. These patients typically have more severe conditions, more comorbidities, or more challenging psychosocial circumstances.
A billing practitioner cannot report both complex and non-complex CCM for the same patient in the same calendar month.
Supervision and Provider Eligibility:
Physicians (MDs and DOs), nurse practitioners (NPs), physician assistants (PAs), clinical nurse specialists (CNSs), and certified nurse midwives can bill for CCM services. Clinical staff delivering CCM services work under the general supervision of the billing practitioner.
Relationship to Other Programs:
CCM and PCM (Principal Care Management) cannot be billed for the same patient in the same month. CCM and APCM (Advanced Primary Care Management) also cannot be billed concurrently. CCM can be billed alongside RPM and BHI for the same patient in the same month, provided that time and documentation are tracked separately for each service and there is no overlap.
Sources:
CMS Medicare Learning Network, "Chronic Care Management Services" (MLN booklet);
42 C.F.R. ยง 414.2; CMS CY 2015 through CY 2026 Physician Fee Schedule final rules;
American Academy of Family Physicians (AAFP) coding guidance.
The Advanta team is ready to discuss the details of Connected Care.
If you have questions, reach out.