What Services are Included in Chronic Care Management? A Guide for Professionals

Chronic Care Management · Care Coordination · Medicare

CCM
CPT 99490
Medicare Billing

The time between office visits plays an important role in managing long-term illness. Acute problems are handled face-to-face, but the day-to-day management of chronic conditions happens at home.

Chronic Care Management (CCM) is the Medicare program the Centers for Medicare & Medicaid Services (CMS) created to support that work. It provides a structured framework and separate reimbursement for the non-face-to-face coordination that eligible patients need.

For practices building or refining a chronic care program, one question comes up often: what services are actually included in CCM? This guide explains the core services, the eligibility rules, and what current CMS frameworks require, so your team can run a compliant program and receive reimbursement for coordination work it may already be doing between visits.

What Chronic Care Management Covers

CCM is a set of care coordination services delivered outside the regular office visit for patients with multiple chronic conditions.

It matters because chronic illness is common in the Medicare population: about two-thirds of Medicare beneficiaries have two or more chronic conditions, according to CMS. Coordinating that care between visits is the work CCM is designed to support.

Who Qualifies for CCM Services

To be eligible for CCM, a patient must meet specific criteria.

These conditions can range from diabetes and hypertension to Alzheimer’s disease, depression, and atrial fibrillation.

For new patients, CMS also expects an initiating face-to-face visit within the prior 12 months before CCM begins. The goal is coordinated care that improves outcomes and makes care more person-centered.

The Core Services Included in CCM

Standard CCM billing under Current Procedural Terminology (CPT) code 99490 requires at least 20 minutes of clinical staff time per calendar month, directed by a physician or other qualified health care professional (QHP). That time cannot be spent on routine administrative filing. It must go toward specific care coordination activities. The core services below make up a compliant program.

Comprehensive Care Planning

The center of CCM is an electronic comprehensive care plan that is developed, implemented, revised, and monitored over time. This is more than routine clinical documentation. It is a patient-centered plan that addresses physical, mental, cognitive, psychosocial, functional, and environmental needs. The plan should be based on a systematic assessment, shared with the patient and caregivers, accessible to authorized providers consistent with patient consent, and updated as the patient’s condition changes.

24/7 Access to Care

Chronic conditions do not follow office hours. CCM requires that patients have 24/7 access to a care team member who can address urgent chronic-care needs. This gives patients a reliable way to get help at any time, which can reduce the likelihood of unnecessary emergency department (ED) visits.

Management of Care Transitions

Moving between care settings, such as a hospital discharge to home or a skilled nursing facility, is a vulnerable time. CCM includes managing these transitions: facilitating referrals to other clinicians, sharing health information with other facilities in a timely way, and following up after discharge so patients understand their instructions.

Medication Management and Reconciliation

For patients with several chronic conditions, medication lists can grow complex. CCM staff oversee the patient’s self-management of medications and reconcile the patient’s medication list with what other providers, such as specialists, have prescribed. This helps reduce the risk of drug interactions.

Coordination With Home and Community Services

Health is shaped by factors outside the clinic. CCM includes coordinating with home- and community-based providers, which can mean working with home health agencies, nutritionists, transportation services, or support groups so the patient has the support needed to follow the treatment plan.

How CCM Affects Patient Outcomes

CCM takes provider time and resources, and the available data points to measurable benefits. A CMS-sponsored evaluation of the CCM program, based on two years of claims data, reported reduced hospitalizations and ED visits among enrolled patients, along with improved adherence to recommended therapies.

Source: CMS-sponsored evaluation of the Chronic Care Management program. See the CMS final evaluation report.

By supporting coordination between visits, CCM helps practices account for, and receive reimbursement for, non-face-to-face work already being performed.

What CMS Requires to Start Billing CCM

Before billing for CCM, a practice must complete a few initiation steps.

Informed Patient Consent

Patients must give verbal or written consent to receive CCM, and that consent must be documented in the medical record. Consent confirms the patient understands that they are agreeing to CCM services, that they can stop at any time, that only one practitioner can bill CCM in a given calendar month, and that cost-sharing such as copayments or deductibles may apply.

A Certified EHR and Structured Data

To coordinate care, the practice must use a certified Electronic Health Record (EHR) that can record structured patient data consistent with CMS requirements. Structured data makes it easier to share information across the care team.

Rates are approximate national non-facility amounts, vary by region, and are updated annually by CMS. Verify current rates with your Medicare Administrative Contractor (MAC).

What Changed for CCM in 2026

The rules for what CCM includes are stable, but the payment and oversight picture shifted for 2026.

How DrKumo Supports CCM Programs

Coordinating the information that CCM requires is easier with secure digital tools. DrKumo provides HIPAA-compliant and FIPS-compliant digital health technology, including Remote Patient Monitoring (RPM), that supports the data flow at the center of chronic care coordination.

RPM is a distinct program from CCM, but the two work together. RPM readings from medical devices as defined by the FDA, such as blood pressure cuffs and glucose meters, give care teams patient-submitted physiologic data between visits, which supports the coordination CCM involves. Providers may bill RPM and CCM for the same patient when each program’s requirements are separately met and documented.

DrKumo centralizes this data in a secure, HIPAA-compliant platform that helps reduce the administrative load of running a CCM program. Its Artificial Intelligence (AI) and Machine Learning (ML) capabilities highlight data trends for clinical review, and the platform supports adherence to the provider-led Disease Management Protocols (DMPs) used for common chronic conditions.

For teams weighing how a comprehensive remote patient monitoring program fits alongside their CCM workflow, DrKumo supplies the technology while clinical decisions stay with the care team.

DrKumo is not a clinical entity and does not provide clinical services. Providers retain full clinical responsibility for patient care decisions.

Key Takeaways

CCM is more than a billing code. It is a structured way to coordinate care for patients with multiple chronic conditions between their office visits. The core services include a comprehensive care plan, 24/7 access to care, management of care transitions, medication reconciliation, and coordination with home and community services.

Standard CCM is billed under CPT 99490 for at least 20 minutes of clinical staff time per month, and it requires patient consent, a certified EHR, and, for new patients, an initiating visit within the prior 12 months. A CMS-sponsored evaluation associated CCM with fewer hospitalizations and ED visits.

DrKumo provides the technology that supports CCM data coordination and is not a clinical entity. Licensed providers remain responsible for all clinical and billing decisions.

Frequently Asked Questions

References

Centers for Medicare & Medicaid Services. Chronic Care Management Services: Payment FAQs. CMS.gov.

Centers for Medicare & Medicaid Services. Evaluation of the Diffusion and Impact of the Chronic Care Management (CCM) Services, Final Report. CMS.gov.

Centers for Medicare & Medicaid Services. Multiple Chronic Conditions Measures Overview. CMS.gov.

American Academy of Family Physicians. Chronic Care Management. AAFP.org.