If you treat Medicare patients with two or more chronic conditions, you may already be doing the work that qualifies for Chronic Care Management (CCM) billing and leaving money on the table every month. This guide covers who qualifies, what to document, and how to run a smooth CCM workflow inside your EHR without hiring extra staff.
Chronic Care Management is a Medicare program that pays your practice for the non-face-to-face care coordination you already provide to patients with multiple chronic conditions, medication refill calls, care plan updates, coordination with specialists, and after-hours calls.
The primary code is CPT 99490, which covers at least 20 minutes of clinical staff time per calendar month. For 2026, the reimbursement rate is approximately $62–$65 per patient per month for the base code under standard Medicare.
For solo and small practices, even 20–30 enrolled patients can add a meaningful revenue stream with no new services, just proper documentation of care you are already delivering.
Your patient must meet all of the following criteria:
|
Requirement |
Details |
Status |
|
Medicare Part B enrollment |
Fee-for-service Medicare (not Medicare Advantage, check plan rules) |
Required |
|
Two or more chronic conditions |
Conditions expected to last at least 12 months or until death |
Required |
|
Conditions place patient at significant risk |
Risk of death, acute exacerbation, or functional decline |
Required |
|
Written patient consent |
Informed consent before first billing month; documents cost-sharing |
Required |
|
Only one practice bills per month |
Patient cannot have two providers billing CCM in the same month |
Exclusion |
Medicare does not publish a fixed list, but conditions that commonly qualify include: Type 2 diabetes, hypertension, heart failure, COPD, coronary artery disease, chronic kidney disease, depression, osteoarthritis, obesity, asthma, atrial fibrillation, and Alzheimer's disease. Any two or more conditions documented in your EHR will likely qualify.
CMS has specific requirements, and a failed audit almost always traces back to one of these:
Before the first CCM billing month, obtain written consent explaining what CCM is, that only one provider can bill per month, that a 20% coinsurance may apply, and that the patient can opt out at any time. Store this in the patient's chart.
Create and maintain a structured, patient-centered care plan accessible 24/7 by any treating provider. It must cover the patient's health problems, expected outcomes, medications, community resources, and care coordination needs. Review and update it at least annually or when the patient's condition changes significantly.
Log at least 20 minutes of clinical staff time per calendar month per enrolled patient. Each entry must show the date, staff member name and credential, activity performed, and minutes spent. If a month falls short of 20 minutes, do not bill that month.
Any clinical staff member can perform CCM services including MAs, nurses, and LPNs, as long as a physician oversees the program and performs the initiating visit.
A simple workflow for practices with one to five providers:
Use your EHR's chronic condition problem list to identify patients with two or more qualifying conditions, run a report monthly.
Flag eligible patients for consent at their next visit using the EHR's built-in consent template.
Create the CCM care plan inside the patient's chart using your EHR's structured care plan module.
Assign monthly care coordination tasks to an MA or nurse; log time as activities happen, not at month-end.
Set a reminder on the 25th of each month to review time logs and confirm the 20-minute threshold before billing closes.
Bill CPT 99490 (or 99491 if the physician personally performs 30+ minutes) in your normal billing cycle.
Billing without a signed consent form on file, the most common audit finding.
Using free-text progress notes instead of a structured care plan.
Logging time in bulk at month-end instead of in real time.
Billing in months where the 20-minute threshold was not reached.
Forgetting to verify that another provider is not already billing CCM for the same patient.
The workflow takes about 30–45 minutes of staff time per week once set up, even starting with just 15 enrolled patients.
Disclaimer: This content is for informational purposes and does not constitute legal or billing advice. Verify current CMS guidelines before billing.