Chronic Care Management (CCM)


Chronic Care Management Program (CCM), as required by CMS to bill for CPT code 99490, involves non– face-to-face (in home) services that must be performed by a physician or other qualified healthcare professionals to patients with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.


These services must be performed for at least 20 minutes once a month to each beneficiary. In addition to the required 20 minutes per month, several other requirements must be met.

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Below is a step-by-step description of requirements needed under the three major categories.

Medicare Beneficiary Requirements

Qualified Medicare Beneficiaries

  • A patient who has been diagnosed with two or more chronic conditions expected to last for at least 12 months, or until death of the patient

Obtaining Medicare Beneficiary Consent
Provider must inform beneficiary of the following:

  • CCM program description
  • Manner in which CCM services will be provided
  • The right to stop the CCM services at any time
  • Only one practitioner can provide these services during a calendar month
  • Health information will be shared with out practitioners
  • Beneficiary will be responsible for associated copays or deductibles

Technology Requirements

EHR Technology Requirements

  • Must be certified – satisfying either the 2011 or 2014 edition of the certification criteria for the EHR Incentive Programs
  • Allow for creation of a structured clinical summary record (consistent with 45 CFR 170.314(e)(2))
  • Provider must be able to transmit the summary record
  • House the beneficiary consent for CCM Services and beneficiary receipt of care plan
  • Document communication to and from home and community-based providers

Electronic Care Plan Requirements (available 24/7)

  • Allow provider to create an electronic care plan based on the physical, mental, psychosocial, cognitive, functional, and environmental assessment of beneficiary
  • Ability to update and share care plan with other practitioners and care
  • Opportunities for beneficiary and any caregiver to communicate with the practitioner

CCM Service Requirements

CCM Service Requirements

  • Chronic Care Management Services Requirements
  • Provide 20+ minutes of non-face-to-face care management services
  • Beneficiary access to care management services 24/7
  • Continuity of care with a designated practitioner/care team member – ability to get successive routine appointments
  • Monitor beneficiary’s condition – care management of chronic conditions
  • Ensure beneficiary receipt of preventive care services
  • Medication reconciliation
  • Oversight of beneficiary self-management of medications
  • Follow up after ER visits
  • Help coordinating transition of care

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