Chronic Care Management 101: An Introduction to Medicare’s CCM Program
Mrs. Thompson, a 74-year-old with diabetes, hypertension, and COPD, sees her primary care physician every few months. In between visits, she juggles multiple medications, specialist appointments, and occasional trips to urgent care when symptoms flare. Her doctor knows these gaps in contact can lead to preventable complications, but traditional fee-for-service care doesn’t reimburse for the time spent managing her care outside the exam room.
That’s where Medicare’s Chronic Care Management (CCM) program changes the equation — reimbursing providers for structured, ongoing coordination that keeps patients like Mrs. Thompson healthier and more engaged year-round.
What is Chronic Care Management (CCM)?
Chronic Care Management is a Medicare-covered service that pays eligible providers for delivering non-face-to-face care coordination to patients with multiple chronic conditions. It recognizes that managing chronic illness is a continuous process, not confined to office visits, and rewards providers for work that often goes uncompensated in a fee-for-service model.
Its core principles focus on proactive management of long-term conditions, enhancing patient engagement between visits, and maintaining structured workflows and documentation to ensure quality and compliance.
Who is Eligible for CCM?
Eligibility isn’t open to every patient; CMS defines it precisely so the program targets those who will benefit most:
- Two or more chronic conditions.
- Conditions expected to last at least 12 months, or until the patient’s death.
- Conditions place the patient at significant risk of death, acute exacerbation, or functional decline.
The billing practitioner must be responsible for ongoing care of all the patient’s chronic conditions, and the patient must be an established patient.
Examples of qualifying chronic conditions span multiple specialties:
This clarity helps practices target outreach to the right patients and set clear expectations from the start.
What Services Does CCM Include?
CCM is much more than a monthly check-in — it’s a structured care program designed to keep patients on track between visits. CMS requires that CCM include:
- Comprehensive Care Plan — Developed with patient input, stored electronically, and shareable across the care team. It must address physical, mental, cognitive, psychosocial, functional, and environmental needs, and be updated as situations change.
- Monthly Follow-Up and Coordination — At least 20 minutes of time each calendar month from the care team (or from the billing practitioner for certain codes) to review labs, adjust medications, coordinate with specialists, or follow up after hospitalizations.
- 24/7 Access to Care Management — A way for patients to reach their care team after hours for urgent needs related to their chronic conditions.
- Documentation and Compliance — Documented consent that covers program details, any cost-sharing, and the right to revoke; code-specific time logs; and records that match CPT definitions.
By combining these elements, CCM creates a continuous thread of care that closes gaps, reduces fragmentation, and gives patients confidence that their health is being monitored even when they’re not in the clinic.
How CCM Improves Patient Outcomes
The value of CCM is best seen in its real-world impact:
- Better disease control: Monthly reviews catch trends early — a patient with diabetes showing rising A1C levels can have their care plan adjusted before complications develop.
- Improved engagement: Consistent, structured contact fosters trust and keeps patients accountable for medications, follow-ups, and lifestyle goals.
- Enhanced coordination: A single care plan, accessible to all providers, reduces conflicting treatments and duplication of tests.
- Evidence-based benefits: Peer-reviewed studies associate CCM participation with lower hospitalization rates and better treatment adherence in certain populations.
These gains aren’t automatic — they come from consistent processes, thoughtful patient engagement, and using each monthly contact to its full potential.
Why CCM is a Win for Practices
CCM isn’t just good medicine — it’s good business:
- Predictable revenue: Each enrolled patient generates Medicare reimbursement when requirements are met. At CY2025’s national non-facility rate (~$62 for 99490), enrolling 100 patients can create significant annual income, with exact rates varying by locality and year.
- Operational streamlining: Standard workflows for chronic care make it easier to manage patient panels efficiently, often benefiting other service lines.
- Quality improvement: Meeting QPP metrics and payer quality benchmarks becomes easier with consistent chronic care processes.
- Patient loyalty: Patients who feel supported between visits are more likely to remain with the practice.
When implemented well, CCM pays dividends in patient health, provider satisfaction, and financial performance.
Implementation Strategy
Rolling out CCM successfully requires structure and planning:
- Identify eligible patients: Use EHR reports to find those with ≥2 qualifying conditions, prioritizing high-utilization or high-risk cases.
- Build standardized workflows: Define who does what — from creating care plans to logging monthly time — and how data is stored.
- Train the team: Cover CMS rules, billing, documentation, and patient engagement techniques.
- Engage patients effectively: Explain benefits in plain language, address cost-sharing concerns, and document consent.
- Track and adjust: Monitor enrollment, time logged, outcomes, and billing accuracy.
- Scale up: Once workflows are stable, expand enrollment and consider adding complementary services like Remote Patient Monitoring.
The more deliberate your launch, the more likely CCM will become a sustainable, high-value part of your care model.
Common Pitfalls and How to Avoid Them
Even strong programs can stumble if these aren’t addressed:
- Documentation gaps: Missing consent, outdated plans, or incomplete time logs can derail reimbursement.
- Low enrollment: Overlooking eligible patients leaves care and revenue on the table.
- Workflow strain: Adding CCM without redesigning roles and schedules can burn out staff.
Clear processes, automation where possible, and defined responsibilities keep the program running smoothly.
Compliance and Audit Readiness
Sustaining CCM means staying audit-ready:
- Keep patient consent, care plans, and monthly logs up to date.
- Ensure services align exactly with the CPT definitions for the codes billed.
- Separate and track time if CCM is billed alongside other care management services.
Lara Health manages eligibility checks for the program, embeds compliant workflows, tracks billable time by code, and integrates directly with your EHR, making compliance a natural part of your daily workflow.
Conclusion
Chronic Care Management offers a proven, reimbursable way to improve outcomes for complex patients while creating sustainable revenue. For practices serving Medicare age patients, CCM is both a clinical and financial opportunity too important to ignore.
Ready to launch CCM in your practice? Learn more about CCM with Lara Health and see how our platform makes implementation, compliance, and scaling straightforward.
FAQs
Who can bill for CCM?
Physicians, nurse practitioners, physician assistants, and certain clinical nurse specialists providing ongoing care for all chronic conditions.
Can specialists bill for CCM?
Yes, if they meet CMS requirements and coordinate all chronic care for the patient.
Is patient consent required?
Yes — verbal or written, covering program details, costs, and the right to revoke, must be documented.
Can CCM be billed with other care management services?
Yes, as long as time and activities aren’t double-counted.
What’s the basic time requirement?
99490 requires at least 20 minutes of clinical staff time/month; other codes have different thresholds.
References
CMS — MLN909188 Chronic Care Management Services. June 2025
AMA — CPT 2025 Professional Edition
Peikes D, et al., Impact of Chronic Care Management on Hospitalization and Adherence. JGIM, 2022
Bleser WK, et al. , Medicare CCM and Outcomes: Multi-site Evaluation. Health Affairs, 2021
