Healthcare Glossary→CCM
Clinical Measures

CCM: Chronic Care Management

Chronic Care Management (CCM) is a CMS-reimbursed programme that provides structured care management services to Medicare patients with two or more chronic conditions, generating $42–92 per patient per month in additional practice revenue.

What is Chronic Care Management?

Chronic Care Management (CCM) is a Medicare programme introduced by CMS in 2015 that provides reimbursement for non-face-to-face care coordination services for patients with two or more chronic conditions expected to last at least 12 months or until death, placing the patient at significant risk of death, acute exacerbation, or functional decline. CCM services include care plan development, medication management, coordination between providers, patient and caregiver education, and care transition support.

CCM CPT Codes and Reimbursement

  • CPT 99490: Standard CCM — 20+ minutes of non-face-to-face care coordination per calendar month. Approximately $62/month Medicare reimbursement. Can be provided by clinical staff under supervision.
  • CPT 99439: Each additional 20 minutes of CCM beyond 99490. Approximately $47/month. Can be billed multiple times in same month.
  • CPT 99491: Complex CCM — 30+ minutes of non-face-to-face time performed personally by the billing physician or qualified health professional. Approximately $86/month. Higher threshold but also higher reimbursement.
  • CPT 99487: Complex CCM — 60 minutes. Approximately $131/month for cases requiring substantial revision of care plan.

Required Elements

CCM billing requires: a comprehensive care plan (accessible to all treating providers), patient consent (documented and withdrawal-capable), 24/7 access to clinical staff, structured recording in a certified EHR, medication reconciliation monthly, and management of care transitions. The care plan must be developed collaboratively with the patient and include problem list, expected outcome goals, treatment goals, medication review, and community resources.

CCM Programme Revenue Modelling

A primary care practice with 1,500 Medicare patients and 60% chronic disease prevalence has approximately 900 CCM-eligible patients. If 40% enrol and are maintained each month, that is 360 patients generating ~$62/month = $22,320/month or $267,840/year in incremental Medicare revenue without requiring physician time for the CCM services themselves. CCM is widely considered one of the highest-ROI, most underutilised Medicare revenue opportunities in primary care.