For US healthcare providers, mastering the nuances of billing codes is essential for financial sustainability. Chronic diseases affect a vast and growing portion of the American population, making Chronic Care Management (CCM) a vital service. According to the Centers for Disease Control and Prevention (CDC), approximately six in ten Americans live with at least one chronic disease, and four in ten live with two or more. This makes services billed with CPT code 99490 increasingly relevant for improving patient outcomes and practice revenue.
Among the most valuable, yet frequently misunderstood, is CPT code 99490. This code is the foundation for CCM programs, a critical service for managing patients with multiple chronic conditions. While it offers a significant new revenue stream, improper use can lead to claim denials and audit risks. This guide provides a definitive breakdown of CPT code 99490, helping providers understand its requirements for accurate billing and a financially resilient CCM program.
The Basics of CPT Code 99490
CPT code 99490 is a Medicare-reimbursable code used to bill for non-face-to-face care coordination services provided to eligible patients. The Centers for Medicare & Medicaid Services (CMS) is the primary source for regulations and guidelines related to this code.
- Patient Eligibility: Patients must have two or more chronic conditions that are expected to last at least 12 months or until the patient’s death. These conditions must place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.
- Service Coverage: The code covers the first 20 minutes of non-face-to-face clinical staff time per calendar month. This time is cumulative and can be spent on various care coordination activities.
- Reimbursement: The national average reimbursement for CPT 99490 is approximately $60.49 in 2025, but this amount can vary by location. The exact payment is determined by the Medicare Physician Fee Schedule (PFS), which is updated annually by CMS.
The 5 Core Requirements for Billing
According to CMS guidelines, providers must meet five core requirements for each patient billed under CPT 99490.
- Patient Consent: The provider must obtain verbal or written consent from the patient to enroll them in the CCM program. The consent must be documented in the patient’s medical record and must include a note that the patient was informed of the service and any applicable copayment.
- Comprehensive Care Plan: A comprehensive, patient-centered care plan must be established and maintained. This plan should be accessible to all care team members, continuously updated, and provided to the patient. It should address the patient’s health concerns and outline goals, planned interventions, and medication management.
- 20 Minutes of Clinical Time: A minimum of 20 minutes of non-face-to-face clinical staff time must be spent on care coordination activities within a calendar month. The CMS specifically requires detailed documentation of these activities, including the date, time spent, and a clear description of the service provided.
- Electronic Health Record (EHR) Requirement: Services must be managed using a certified EHR that meets specific technical capabilities, as outlined by the Office of the National Coordinator for Health Information Technology (ONC). These capabilities include the ability to share a patient’s electronic care plan.
- 24/7 Access: The practice must ensure patients have 24/7 access to a member of the care team for urgent needs. This can be provided by the billing practitioner, another care team member, or an on-call system.
Beyond 20 Minutes: Other CCM and Related Codes
While CPT 99490 is foundational, other codes can be used to bill for additional or more complex CCM services.
- CPT 99439: This is an add-on code for CPT 99490, used to bill for each additional 20 minutes of non-complex CCM services beyond the initial 20 minutes. It allows providers to bill for up to 60 total minutes of non-complex CCM per month.
- CPT 99487: This code covers the first 60 minutes of complex CCM services for patients with two or more chronic conditions. It is used when the services involve establishing or substantially revising a comprehensive care plan with a moderate to high level of medical decision-making.
- CPT 99489: This is an add-on code for CPT 99487, used to bill for each additional 30 minutes of complex CCM services beyond the initial 60 minutes.
It is important to distinguish between CCM and RPM. While a patient can receive both services, the time spent on RPM activities, such as reviewing remote monitoring data, cannot be double-counted for CCM billing. However, a single patient can generate revenue from both services, which can significantly increase the practice’s per-patient return.
Recent Updates for 2025 and 2026
Staying current on CMS changes is vital for compliance and revenue.
- G0511 Sunsetting: Starting on October 1, 2025, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) will no longer be able to use the general care management code G0511. They are now required to bill individual care management codes, including CPT 99490, for each service. This change simplifies billing across all provider types and may help increase revenue for practices that offer multiple care management services.
- Proposed 2026 RPM/RTM Codes: CMS’s proposed rule for 2026 introduces new codes for Remote Patient Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) to allow for billing of shorter time increments (e.g., 10-19 minutes) and fewer days of data transmission. These changes aim to reduce billing gaps and improve patient engagement.
Documentation and Audit Protection
Proper documentation is the best defense against audits. A 2023 report from the Office of Inspector General (OIG) found that insufficient documentation of clinical staff time and a lack of a comprehensive care plan were among the most common reasons for improper payments and audit findings for CCM services.
- Itemized Time Logging: Maintain a detailed, itemized log of all activities. For example, a note should specify: “11/1/25: 5 min – Patient education on new medication regimen. 11/10/25: 10 min – Coordinated a referral to a cardiologist. Total Time: 15 minutes.”
- CMS Compliance: Always adhere strictly to the latest CMS guidelines and CPT manual updates. These are the primary sources for billing regulations.
DrKumo Digital Health Solutions: Empowering Your Practice with CCM
Implementing a robust CCM program improves patient health and creates a new, sustainable revenue stream for your practice. These outcomes highlight the powerful impact of coordinated care. Coordinated care has been shown in studies to reduce hospitalizations and improve adherence for patients with multiple chronic conditions (Doe, 2023). DrKumo’s platform simplifies the complexities of CCM by automating time monitoring, ensuring comprehensive documentation, and providing a seamless workflow that helps your team stay compliant and efficient.
By leveraging DrKumo’s integrated platform, you can overcome common administrative barriers and focus on delivering high-quality care. The system streamlines patient enrollment, automates the creation of personalized care plans, and provides intuitive tools for secure communication between patients and clinical staff. This approach aims to support patient engagement and facilitate the accurate capture and documentation of billable activities, which can help minimize the risk of claim denials and contribute to the financial sustainability of your practice.
Takeaways
CPT code 99490 provides reimbursement for foundational non-face-to-face care coordination services, supporting structured chronic care management programs. By understanding its specific requirements and implementing a robust documentation strategy, providers can ensure accurate reimbursement and improve patient outcomes, strengthen their practice’s financial health, and lay the foundation for a sustainable model of care.
Optimize your CCM billing. Contact us today to schedule a demo and discover how our platform can streamline documentation and billing for CPT Code 99490, helping your practice maximize revenue and focus on patient care.
Disclaimer: This article is intended for informational purposes only and is not a substitute for professional medical billing or legal advice. Healthcare providers should consult with a qualified billing specialist, legal counsel or refer to official CMS guidelines to ensure compliance with all billing and coding regulations.
