What is Chronic Care Management?

The Centers for Medicare & Medicaid Services recognize Chronic Care Management (“CCM”) as a critical component of primary care that contributes to better health and care for individuals.

In 2015, Medicare began paying separately under the Medicare Physician Fee Schedule (CPT 99490) for non Face to Face services furnished to Medicare patients with multiple chronic conditions.

CCM services include at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements:

  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
  • Chronic conditions place the patient at significant risk of death, acute exacerbation / decompensation, or functional decline
  • Comprehensive care plan established, implemented, revised, or monitored

Examples of chronic conditions include, but are not limited to, the following:

  • Alzheimer’s disease and related dementia
  • Arthritis (osteoarthritis and rheumatoid)
  • Asthma
  • Atrial fibrillation
  • Autism spectrum disorders
  • Cancer
  • Cardiovascular Disease
  • Chronic Obstructive Pulmonary Disease
  • Depression
  • Diabetes
  • Hypertension
  • Infectious diseases such as HIV/AIDS

In 2017, CMS allowed for Patient verbal enrollment to initiate CCM services.  For new patients or patients not seen within one year prior to the start of CCM, Medicare requires an annual wellness visit (AWV) and allows for CCM enrollment reimbursement during a face-to-face visit with the billing practitioner and is separately billed.

CCM services include structured recording of patient health information, maintaining a comprehensive electronic care plan, managing transitions of care and other care management services, and coordinating and sharing patient health information timely within and outside the practice.

Medicare typically reimburses roughly $40+ per month per billed patient.