What are the CPT codes for CCM?

Notes: Payer policies vary. Confirm local coverage and plan requirements before submission.

Who can bill CCM services?

• Physicians (MD, DO)

• Other qualified health care professionals such as NPs and PAs

• RHCs and FQHCs under G0511, when applicable

Clinical staff may perform many CCM activities under the general supervision of the billing practitioner, consistent with state law and payer rules.

Patient eligibility and program requirements

Patients must have two or more chronic conditions that are expected to last at least 12 months, or until death, and place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline.

A compliant CCM program includes:

• A comprehensive, patient-centered care plan, established, implemented, revised, or monitored

• 24/7 access to urgent care management and a means to reach someone with access to the care plan

• Continuity of care with a designated practitioner or care team

• Systematic assessment, medication reconciliation, and coordination with external clinicians and community resources

• Informed consent documented in the medical record, including cost-sharing information

Billing requirements and best practices

• Do not double count time. CCM minutes cannot overlap with time billed for other timed services in the same month.

• Track time by code family. Maintain separate logs for 99490/99439, 99491/99437, and 99487/99489.

• Document work clearly. Note date, staff role, duration, and a brief description that ties activity to the care plan.

• Maintain the care plan. Store in a shareable format accessible to the care team and the patient.

• Obtain and renew consent. Keep consent current and visible in the chart.

• Use add-on codes appropriately. Report 99439 only with 99490, and 99437 only with 99491. Report 99489 only with 99487.

Sample documentation language

1. 99490 example
   “Chronic Care Management for two conditions: Type 2 diabetes and hypertension. Reviewed home BP logs, reconciled medications, coordinated dietitian referral, and updated care plan goals. 26 minutes of clinical staff time this month under general supervision.”

2. 99439 example
   “Additional CCM activities: arranged nephrology follow-up, confirmed transportation resources, and monitored adherence to new ACE inhibitor. Additional 22 minutes of clinical staff time.”

3. 99491 example
   “Physician CCM. Personally reviewed recent lab results and SMBG trends, discussed GLP-1 titration and hypoglycemia precautions with patient by phone, and updated care plan. 34 minutes of physician time this month.”

4. 99487 example
   “Complex CCM due to heart failure, CKD stage 3, and diabetes with recent decompensation. Moderate to high complexity medical decision making. 68 minutes of clinical staff time coordinating cardiology and nephrology plans, monitoring weights and renal dosing, and updating the comprehensive care plan.”

CCM quick reference

• 99490: At least 20 minutes of clinical staff time in a month tied to the care plan

• 99439: Each additional 20 minutes of clinical staff time, with 99490

• 99491: At least 30 minutes of physician or QHP personal time in a month

• 99437: Each additional 30 minutes of physician or QHP personal time, with 99491

• 99487: Complex CCM, at least 60 minutes of staff time with moderate to high complexity MDM

• 99489: Each additional 30 minutes with 99487

• G0511: Use for RHC/FQHC per CMS guidance

Frequently asked questions

1. Do CCM minutes need to be continuous?
   No. Minutes may accrue over the calendar month. Record cumulative time and supporting activities.

2. Can I bill 99490 and 99491 in the same month for the same patient and practitioner?
   Generally no. Do not report 99490 with 99491 by the same practitioner for the same patient in the same month. Use the code set that best reflects who performed the work and the nature of the service.

3. Can CCM be provided concurrently with RPM or PCM?
   Often yes, provided the services are distinct, time is not double counted, and documentation demonstrates separate scope and purpose. Follow payer policy.

4. Is a new consent required every month?
   No. Obtain and document informed consent before initiating CCM and update as policy or patient preference requires.

5. What belongs in a compliant care plan?
   Diagnoses, measurable goals, self-management instructions, medication list, responsible clinicians, scheduled interventions, and coordination needs. Store in a format that the team and the patient can access.

Ready to implement CCM?

OnCare360 supports CCM operations with care coordination workflows, time tracking, documentation templates, and payer-aligned reporting.