Structured Health Record
Patient demographics, problems, medications and allergies recorded in a structured electronic format, kept current by e-Vitals.
Chronic Care Management Without The Spreadsheet Of Minutes
e-Vitals keeps care plans, monthly outreach and time tracking in one place, so your team can coordinate care for patients with multiple chronic conditions and document it as they go.
What Is Chronic Care Management?
Chronic Care Management is non-face-to-face care coordination for patients with two or more chronic conditions expected to last at least 12 months.
It covers the work between visits: maintaining a comprehensive care plan, managing medications, coordinating with other providers and checking in with the patient each month.
Who Qualifies For CCM
- Two or more chronic conditions expected to last at least 12 months, or until the patient's death.
- Conditions that place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline.
- An initiating visit for new patients (or any patient not seen within the past year).
- Documented patient consent, verbal or written, captured before billing.
- A comprehensive, patient-centered electronic care plan that is shared and maintained.
Example Chronic Conditions
Not an exhaustive list. Any two or more qualifying chronic conditions can make a patient eligible.
Alzheimer's & related dementiaArthritisAsthmaAtrial fibrillationAutism spectrum disordersCancerCardiovascular diseaseCOPDDepressionDiabetesGlaucomaHIV / AIDSHypertensionSubstance use disorders
What CCM Includes
CMS defines the core elements of a compliant CCM program. e-Vitals operationalizes every one of them.
Comprehensive Care Plan
A patient-centered electronic plan: problem list, goals, planned interventions, medication management and periodic review.
24/7 Access & Continuity
Around-the-clock access for urgent needs and a designated care team member the patient can reach, supported by secure messaging and scheduling.
Comprehensive Care Management
Assess medical, functional and psychosocial needs, ensure preventive services, and oversee medication self-management between visits.
Manage Care Transitions
Coordinate referrals and follow-up after ED visits or discharges, and exchange continuity-of-care documents with other providers.
Coordinate & Share
Share patient information promptly within and outside the practice, captured once in a shared, audit-ready timeline.
How CCM Works Each Month
- 01
Initiating Visit
Required only for new patients or those not seen in the past year, completed during a comprehensive E/M visit, Annual Wellness Visit or IPPE. It's separately billable.
- 02
Patient Consent
Obtain and document verbal or written consent, covering cost sharing, that only one practitioner bills per month, and the right to stop anytime.
- 03
Build The Care Plan
Establish a patient-centered electronic care plan and share it with the patient, caregiver and care team.
- 04
Deliver & Log Care
Provide care coordination between visits and log the qualifying time: at least 20 minutes of clinical staff time for the month.
- 05
Document & Bill
Submit the correct CPT code(s) for the time and complexity delivered that calendar month, with audit-ready documentation behind every minute.
How e-Vitals Simplifies CCM
- 01
Care Plans Live With The Patient Record
Goals, conditions, medications and next steps sit alongside the patient's readings and notes in a single view.
- 02
Monthly Outreach Stays On Schedule
Check-ins are queued for your care team, so no enrolled patient goes a month without contact.
- 03
Time Is Captured As Work Happens
Care coordination time is logged to the second against the patient, building toward 99490 and its add-on units.
- 04
Reports Are Ready When The Month Closes
Auditable, billing-ready reports are mapped to CMS CPT codes, with each patient's eligibility shown before you submit.
How Much Do CCM CPT Codes Reimburse?
| CPT Code | What it covers | Time / requirement | Est. reimbursement* |
|---|---|---|---|
| 99490 | Non-complex CCM, first 20 minutes | 20 minutes of clinical staff time in a month | ~$62.40 / month |
| 99439 | Non-complex CCM, each additional 20 | Each additional 20 minutes (up to 2 units) | ~$47.90 / unit |
| 99491 | CCM by physician, first 30 minutes | 30 minutes personally spent by physician or QHP | ~$85.50 / month |
| 99437 | CCM by physician, each additional 30 | Each additional 30 minutes of physician or QHP time | ~$60.20 / unit |
| 99487 | Complex CCM, first 60 minutes | 60 minutes with moderate or high complexity decisions | ~$132.80 / month |
| 99489 | Complex CCM, each additional 30 | Each additional 30 minutes after 99487 | ~$71.50 / unit |
Complex Vs. Non-Complex
Complex CCM (99487/99489) needs 60+ minutes and moderate-to-high-complexity decision making. You can't bill complex and non-complex CCM for the same patient in one month.
Who Can Bill
Physicians, NPs, PAs, clinical nurse specialists and certified nurse-midwives, plus RHCs, FQHCs and hospitals. Only one practitioner bills per patient per month.
Supervision
Clinical staff codes are furnished under general supervision. The billing practitioner directs the care but needn't be physically present.
*Reimbursement figures are approximate 2026 Medicare national-average non-facility rates for educational purposes only and are not billing, legal, or financial advice. Rates change annually and vary by payer and locality. Verify against the current Medicare Physician Fee Schedule before billing. CPT® is a registered trademark of the American Medical Association.
Billing It Right: What Runs Together, What Doesn't
CCM can be combined with several services, and is mutually exclusive with others. e-Vitals tracks time per program so distinct minutes stay distinct.
Can Run Alongside CCM
- Remote patient monitoring (RPM): can be billed in the same month as CCM when the time counted toward each is distinct.
- Transitional care management (TCM): can be billed concurrently with CCM when medically necessary; the same minutes can't count toward both.
- The initiating visit: a comprehensive E/M visit, AWV or IPPE is separately billable and isn't part of CCM time.
- Principal care management (PCM): allowed when a different practitioner manages a different condition (not the same practitioner for the same patient in the same month).
Can't Be Billed Together
- Non-complex and complex CCM together: 99490 / 99439 can't be reported in the same month as 99491 / 99437 or 99487 / 99489.
- Home health supervision (G0181), hospice care supervision (G0182), or certain ESRD services (90951–90970).
- Any time already counted toward another billed code. CCM minutes can never be counted twice.
CCM Fits The Patients You Already Manage
The signals that matter most differ by specialty.
Primary Care
Coordinate care for patients living with several chronic conditions at once.
Cardiology
Keep heart failure and hypertension patients on their plan between appointments.
Endocrinology
Support diabetes patients with regular check-ins and medication follow-up.
Nephrology
Manage the comorbidities that travel with chronic kidney disease.
CCM Questions, Answered
What is Chronic Care Management (CCM)?
CCM is a Medicare-paid service for managing a patient's two or more chronic conditions expected to last at least 12 months (or until death). It covers the largely non-face-to-face care coordination patients need between visits: maintaining a care plan, managing medications and coordinating with other providers. Medicare has paid for CCM separately under the Physician Fee Schedule since 2015.
Which patients are eligible for CCM?
Patients with two or more chronic conditions expected to last at least 12 months (or until death) that place them at significant risk of death, acute exacerbation or decompensation, or functional decline. About two in three Medicare beneficiaries have two or more chronic conditions, so a large share of a typical panel may qualify.
Who can bill for CCM?
Physicians (MD/DO) and certain non-physician practitioners: nurse practitioners, physician assistants, clinical nurse specialists and certified nurse-midwives. RHCs, FQHCs and hospitals (including critical access hospitals) may also bill. Only one practitioner can bill CCM for a given patient in a calendar month.
Is an initiating visit required before starting CCM?
Only for new patients, or patients not seen by the billing practitioner within the previous year. It must be a comprehensive E/M visit, Annual Wellness Visit (AWV) or Initial Preventive Physical Exam (IPPE), and CCM must actually be discussed at that visit.
Is patient consent required, and can it be verbal?
Yes. Consent is required before billing, and it may be verbal or written. Inform the patient that cost sharing may apply, that only one practitioner can bill CCM per month, and that they can stop at any time, then document it.
What's the difference between non-complex and complex CCM?
Non-complex CCM (99490, with add-on 99439) covers routine care coordination starting at 20 minutes of clinical staff time per month. Complex CCM (99487, with add-on 99489) requires at least 60 minutes of clinical staff time and moderate-to-high-complexity medical decision making by the billing practitioner. You can't bill both for the same patient in the same month.
Can RPM and CCM be billed in the same month?
Yes. For an eligible patient, remote patient monitoring can be billed in the same month as CCM, as long as the time counted toward each service is distinct. e-Vitals tracks each program separately so the documentation holds up.
What services can't be billed in the same month as CCM?
CCM can't be reported with home health supervision (G0181), hospice care supervision (G0182) or certain ESRD services (90951–90970). Non-complex and complex CCM are mutually exclusive in a given month, and CCM time can't be double-counted toward any other billed code.
Build A Modern, Scalable CCM Program
See how e-Vitals helps your practice launch, run and document Medicare care programs with devices, onboarding, clinical dashboards and billing support in one platform.