Services · CCM
Chronic Care Management, built to pair with RPM.
Reimbursable, largely non-face-to-face care coordination for patients with two or more chronic conditions — running right alongside your RPM program, in the same dashboard.
Overview
What is CCM?
Chronic care management is the coordination patients with multiple chronic conditions need between office visits — maintaining a care plan, reconciling medications, managing care transitions, and staying in touch. Medicare has paid for it separately under the Physician Fee Schedule since 2015.
Unlike RPM, which is driven by device readings, CCM is driven by documented care-coordination time — so it needs no device, and both programs can run for the same eligible patient at once.
Eligibility
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.
Scope of service
What CCM includes
CMS defines the core elements of a compliant CCM program. eVitals operationalizes every one of them.
Structured health record
Patient demographics, problems, medications, and allergies recorded in a structured electronic format — kept current by eVitals.
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 it works
How CCM works each month
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.
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.
Build the care plan
Establish a patient-centered electronic care plan and share it with the patient, caregiver, and care team.
Deliver & log care
Provide care coordination between visits and log the qualifying time — at least 20 minutes of clinical-staff time for the month.
Document & bill
Submit the correct CPT code(s) for the time and complexity delivered that calendar month, with audit-ready documentation behind every minute.
Billing
CCM CPT codes
Billed on documented monthly time — no device required. Code by who delivers the care and how long it takes.
| CPT | What it covers | Frequency | Approx. avg* |
|---|---|---|---|
| 99490 | CCM — first 20 minutes Clinical staff time directed by a physician/QHP; first 20 minutes. | Monthly | $60–62 |
| 99439Add-on | CCM — each additional 20 minutes Add-on to 99490 for each additional 20 minutes (up to 2 units). | Monthly (add-on) | $45–48 |
| 99491 | CCM by physician/QHP 30 minutes provided personally by the physician or QHP. | Monthly | $82–86 |
| 99437Add-on | CCM by physician/QHP — each additional 30 minutes Add-on to 99491 for each additional 30 minutes of physician/QHP time. | Monthly (add-on) | $58–60 |
| 99487 | Complex CCM — 60 minutes Complex CCM requiring moderate/high-complexity decision making. | Monthly | $130–134 |
| 99489Add-on | Complex CCM — each additional 30 minutes Add-on to 99487 for each additional 30 minutes. | Monthly (add-on) | $70–72 |
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 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.
Approximate national averages; actual payment varies by payer, locality, and program mix. Not billing advice — verify against the current Medicare Physician Fee Schedule. CPT© is a registered trademark of the AMA.
Concurrent billing
Billing it right — what runs together, what doesn't
CCM can be combined with several services — and is mutually exclusive with others. eVitals 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.
The combined opportunity
Bill RPM and CCM together — compliantly.
For an eligible patient, RPM and CCM may both be billed in the same calendar month as long as the time counted toward each is distinct. eVitals tracks each program separately so the documentation holds up to audit.
Estimate combined revenueFAQ
Chronic Care Management FAQs
Answers based on current CMS guidance (MLN909188) and the CMS practitioner billing FAQ. This is general information, not billing advice — confirm details against current CMS and payer rules.