Medicare Chronic Care Management (CCM): A Clinic Guide

Medicare Chronic Care Management (CCM) is an essential program that allows clinics to improve patient outcomes while receiving reimbursement for providing ongoing care to patients with chronic conditions. This program isn’t just a bonus; it’s a game-changer. With updates introduced for 2025, it's now more practical than ever for doctors, nurses, and care teams—especially those in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)—to leverage CCM services and be compensated for the vital work they’re already doing.

In this comprehensive guide, we walk you through everything clinics need to know to efficiently implement and bill for CCM. From eligibility to documentation and avoiding billing conflicts, we’ve broken it all down using the most up-to-date and trusted guidelines from the Centers for Medicare & Medicaid Services (CMS), the American Academy of Family Physicians (AAFP), ThoroughCare, and other top sources.

Whether you’re new to CCM or refining your existing program, this guide will make sure your process is accurate, compliant, and profitable.

What Is Medicare Chronic Care Management (CCM)?

Medicare Chronic Care Management (CCM) is a Medicare program designed for patients with two or more chronic conditions that are expected to last at least 12 months—or until the patient’s death—and that place them at significant risk of health decline or death. This initiative focuses on coordinating care between different healthcare providers and delivering consistent attention to patients, most of which happens outside of the traditional office visit.

CCM is all about helping clinics stay connected with patients, reducing hospitalization risks, lowering emergency room visits, and overall saving lives through preventive measures. Even better, these services are billable on a monthly basis when minimum time requirements are met, enabling providers to reinforce their practice’s financial health.

CMS introduced CCM in 2015, and now, with expanded scope and updates to CPT codes in 2025, the program continues to evolve to better support practices and patient care efforts. According to CMS’s official guidance, CCM can include services like medication management, follow-up appointments, coordination with specialists, and patient education. All of these can happen outside a traditional face-to-face appointment format, giving clinics more flexibility to manage care effectively (CMS.gov).

Patient Eligibility Requirements

For clinics aiming to implement Medicare Chronic Care Management, identifying eligible patients is step one. Here’s how to determine eligibility—and ensure your practice stays compliant.

Eligibility Criteria

To qualify for CCM services, a patient must meet the following conditions:

Have two or more chronic conditions.
The conditions must be expected to last at least 12 months or until the patient’s death.
The conditions must pose a risk of death, acute decompensation (a sudden worsening), or functional decline (ThoroughCare).

Some common qualifying chronic conditions include:

Diabetes
Hypertension
Heart failure
COPD
Arthritis
Depression

Patient Consent

Before providing CCM services, your clinic must obtain either a written or verbal consent from the patient. This step is crucial to make sure the patient understands:

What CCM services include.
That they may be subject to co-pays or deductibles.
That they can opt out at any time.

This consent should be obtained during an in-person visit, often during an Annual Wellness Visit or other comprehensive evaluation visit (AAFP).

Documented Care Plan

Your clinic must create and electronically maintain a comprehensive care plan. This plan will typically include:

A list of current medical problems.
Personalized care goals.
Routine follow-ups and interventions.
Coordination with special care providers.
Emergency contact information.

Not only does this care plan guide treatment—it’s also essential for billing and auditing purposes.

Time Tracking and Billing: How to Track Services Like Billable Hours

Accurately documenting time is one of the most important parts of a successful CCM program. Think of it like logging billable hours in a law firm. Every minute matters!

Trackable Activities

Here are examples of non-face-to-face activities that count toward billable time:

Phone calls with the patient or caregivers.
Updating medication lists.
Coordinating care with other providers.
Health education and patient coaching.
Updating the care plan or problem list.
Electronic communication through secure patient portals.

All these actions must be documented in the patient’s electronic health record (EHR) with date, duration, and description.

Time Requirements by CPT Code

CMS provides specific CPT codes for billing based on time and complexity. Here’s a breakdown:

CPT Code	Description	Time Requirement	2025 Reimbursement*
99490	Non-complex CCM	≥ 20 minutes	~$62
99439	Add-on: Extra non-complex CCM	+20 minutes	~$48
99487	Complex CCM	≥ 60 minutes	~$134
99489	Add-on: Extra complex CCM	+30 minutes	~$64
99491	Provider-delivered CCM	≥ 30 minutes	~$85

*Rates vary slightly by geographic region and are based on the 2025 Physician Fee Schedule with RVU multiplier of $32.05 (Signallamp Health).

2025 CPT Code and Reimbursement Updates

Key Changes to Know

FQHCs and RHCs are now allowed to bill the same CCM CPT codes as traditional fee-for-service practices. The outdated G0511 code is no longer used (ThoroughCare).
Reimbursement values have been updated for CPT codes tied to CCM. These updates help better compensate clinics—especially those that coordinate complex care for elderly or chronically ill patients.

Although CMS hasn't introduced drastic structural changes to the CCM program in 2025, the enhanced codes and payment rates make implementation even more worthwhile (CMS 2025 Final Rule).

Avoiding Billing Conflicts: Don't Double Dip!

Transitional Care Management (TCM)

Be careful—CCM and TCM cannot be billed for the same patient in the same month. TCM includes a 30-day post-discharge period following a hospital or skilled nursing facility stay. If you provide TCM services during that period, you must wait until the next calendar month to bill CCM (CMS Guidance).

Behavioral Health Integration (BHI)

Some elements of CCM and BHI overlap, especially care coordination. To avoid double billing, make sure you’re not billing for the same service under both programs. If you’re offering significant mental health care coordination, you might consider BHI instead—just not both at once (ThoroughCare BHI Billing Rules).

Only One Biller Per Month

Remember: Only one clinic or provider can bill CCM for each patient per calendar month. Even if multiple providers are involved in care, only a single billing claim will be accepted by Medicare.

How Clinics Can Implement CCM Successfully

Implementing Medicare Chronic Care Management may sound like a big task—but with a step-by-step process, your clinic can roll it out smoothly and effectively.

Implementation Checklist

Identify Eligible Patients
- Use your EHR system to flag patients with two or more chronic conditions.
Get Consent
- Incorporate verbal or written consent into new patient visits or Annual Wellness Visits.
Create Care Plans
- Use templates in your EHR to build thorough, personalized care plans for each patient.
Track Time Accurately
- Train your team to document every care activity in real time. Use tracking software to monitor cumulative monthly time per patient.
Staff Roles
- Clinical staff can provide CCM services under general supervision, allowing doctors and NPs to focus on higher-level tasks.
Audit and Review
- Set a monthly review to ensure accuracy in time logs, billing, and patient engagement.

Following this blueprint helps your clinic stay compliant and maintain high-quality care, all while boosting practice revenue.

Frequently Asked Questions (FAQ)

Q1: Can CCM and TCM be billed for the same patient in the same month?

No. CCM and TCM services cannot be billed in the same calendar month for the same patient. You must allow one month to pass after TCM ends before billing for CCM.

Q2: Do I need a physician to deliver CCM services?

CCM can be billed under a physician’s name, but the services themselves can be provided by clinical staff under general supervision. However, CPT 99491 must be completed by a physician or non-physician practitioner.

Q3: What if I don’t meet the 20-minute threshold for the month?

If you don’t reach