White Paper: A Physician's Guide to Billing for Chronic Care Management (CCM)
Date: May 29, 2025
Introduction
Chronic Care Management (CCM) services play a crucial role in managing the health of patients with two or more chronic conditions. Medicare and many other payers recognize the value of these non-face-to-face services by providing reimbursement. This guide offers physicians a concise overview of the key elements involved in successfully billing for CCM, helping to improve patient outcomes and ensure appropriate compensation for the valuable care provided.
Core Requirements for Billing CCM Services
To bill for CCM services, several foundational requirements must be met:
Eligible Patients: Patients must have two or more chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.
Patient Consent: Written or verbal consent (documented in the medical record) must be obtained from the patient before initiating and billing for CCM services. This consent should explain the services, cost-sharing (if any), and the patient's right to stop CCM services at any time.
Comprehensive Care Plan: A person-centered electronic care plan must be established, implemented, revised, or monitored. This plan should be accessible to the patient and all care team members. It typically includes:
A problem list
Expected outcomes and prognosis
Measurable treatment goals
Symptom management
Planned interventions
Medication management
Community/social services ordered
A designated care team member with whom the patient can schedule successive routine appointments.
24/7 Access: Patients must have access to care management services 24 hours a day, 7 days a week. This means having a means for patients to make timely contact with healthcare providers in the practice who have access to their electronic care plan to address urgent chronic care needs.
Care Transitions Management: Support for patients during transitions of care (e.g., discharge from a hospital) is a key component.
Coordination with Home and Community-Based Care: Facilitating access to relevant community resources.
Electronic Health Record (EHR) Use: Utilizing a certified EHR is typically required to document, store, and share patient information and care plans effectively.
Key CPT Codes for Non-Complex CCM
The primary CPT codes for non-complex CCM are time-based and cover services provided by clinical staff under the direction of a physician or other qualified healthcare professional:
CPT Code 99490: Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.
This is the foundational code for CCM.
Requires documentation of at least 20 minutes of qualifying CCM activities.
CPT Code 99439 (formerly G2058): Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure).
This is an add-on code used in conjunction with 99490 for each additional 20-minute increment of CCM services provided in the same calendar month.
Cannot be billed alone.
Important Considerations for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs):
FQHCs and RHCs may use HCPCS code G0511 for general care management, which includes CCM services. G0511 bundles at least 20 minutes of CCM or general behavioral health integration services.
Key CPT Codes for Complex CCM
For patients requiring more intensive management:
CPT Code 99487: Complex chronic care management services, with the following required elements: multiple (two or more) chronic conditions...; chronic conditions that place the patient at significant risk...; establishment or substantial revision of a comprehensive care plan; moderate or high complexity medical decision making; 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.
CPT Code 99489: Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure).
Add-on code for 99487.
Time-Tracking and Documentation: The Cornerstones of CCM Billing
Accurate and meticulous time-tracking and documentation are critical for compliant CCM billing.
Time-Tracking:
All time spent on qualifying CCM activities must be documented. This includes time spent by clinical staff on activities such as:
Care planning
Medication reconciliation and management
Patient communication (phone, secure messaging)
Coordination with other providers, facilities, and community resources
Patient and caregiver education
Only one practitioner can bill for CCM services for a patient in a given calendar month.
Time spent on face-to-face visits cannot be counted towards CCM time.
Documentation: The medical record must clearly reflect:
Patient consent.
The existence of 2+ chronic conditions.
The comprehensive care plan and any updates.
The total time spent by clinical staff on CCM activities for the billing month.
The nature of the activities performed (e.g., "10 min call with patient re: medication side effects," "15 min coordinating home health referral").
The identity of the clinical staff member performing the services.
Evidence of 24/7 access and care continuity.
Common Pitfalls and Best Practices
Pitfalls:
Insufficient or vague documentation of time and activities.
Billing for services without documented patient consent.
Not meeting the minimum time requirement for the billed CPT code.
Billing CCM during the same service period as services that are bundled (e.g., transitional care management, home healthcare supervision, hospice care supervision).
Lack of a comprehensive, person-centered care plan.
Best Practices:
Develop a standardized workflow for identifying eligible patients, obtaining consent, and delivering CCM services.
Utilize EHR templates or flowsheets to streamline documentation of CCM activities and time.
Conduct regular internal audits of CCM billing and documentation.
Train clinical staff thoroughly on CCM requirements and documentation standards.
Clearly communicate the CCM program and its benefits to eligible patients.
Ensure robust communication and care coordination among all members of the care team.
Conclusion
Chronic Care Management offers a significant opportunity to improve the health and well-being of patients with multiple chronic conditions while also providing a sustainable revenue stream for physician practices. By understanding and adhering to the specific requirements for patient eligibility, consent, care planning, service provision, time-tracking, and documentation, physicians can confidently and compliantly bill for these valuable non-face-to-face services. Implementing a structured CCM program can lead to enhanced patient care, better health outcomes, and appropriate reimbursement for the dedicated efforts of the healthcare team.
Disclaimer: This white paper is for informational purposes only and does not constitute medical, legal, or billing advice. Physicians should consult with their billing specialists, legal counsel, and refer to the latest payer guidelines (including Medicare) for specific requirements and updates.