Table of Contents
What is Chronic Care Management ?
Introduction to Chronic Care Management
Key Components of CCM
Benefits of CCM for Patients and Providers
Medicare Beneficiary Eligibility
Provider Eligibility and Qualifications
Chronic Care Management CPT/Billing Codes and Reimbursements
CPT Codes for CCM Services
Reimbursement Rates and Payment Models
Coding and Billing Best Practices
CCM Reimbursement Rates by State (Approximate)
Implementing CCM in Your Practice
Assessing Your Practice's Readiness for CCM
Building a High-Performing CCM Team
Technology and Tools for CCM
Electronic Health Records (EHRs)
Telehealth Platforms
Remote Patient Monitoring Devices
Patient Portals
Data Analytics and Reporting Tools
Developing a Comprehensive Care Plan
Measuring and Improving CCM Performance
Challenges and Opportunities in CCM
Common Challenges in Implementing CCM
Overcoming Barriers to CCM Success
Future Trends in CCM
The Intersection of CCM and Value-Based Care
Value-Based Payment Models and CCM
Strategies for Success in Value-Based Care

What is CCM-Chronic care management?
CCM is a set of services provided by healthcare professionals to individuals with two or more chronic conditions. These services go beyond traditional office visits, focusing on proactive care coordination, patient education, and self-management support. The goal of CCM is to improve patient health outcomes by filling the gaps in between visits to reduce hospitalizations and emergency department visits. This results in enhanced overall quality of life for individuals living with chronic diseases.
For further reading on the importance of CCM in improving chronic disease outcomes, visit the National Institutes of Health (NIH).
Introduction to Chronic Care Management (CCM)
Chronic diseases such as diabetes, heart disease, chronic obstructive pulmonary disease (COPD), and depression are a significant public health challenge. They impact millions of individuals and place a substantial burden on the healthcare system. To effectively manage these conditions and improve patient outcomes, a proactive and coordinated approach is crucial. Enter Chronic Care Management (CCM), a healthcare delivery model designed to provide comprehensive, patient-centered care for individuals with multiple chronic conditions.
Key Components of CCM:
Comprehensive Care Planning: A cornerstone of CCM is the development and implementation of a personalized care plan. This plan outlines the patient's specific health goals, treatment plan, and strategies for managing their conditions. It may include:
Medication management
Monitoring of vital signs and other health indicators
Education on how to manage chronic conditions
Support for lifestyle changes
Coordination of care with other healthcare providers
Coordination of resources such as food, medication, and transportation
Care Coordination: CCM involves close coordination between the patient, their primary care physician, and other members of the healthcare team, such as specialists, nurses, pharmacists, and social workers. This ensures that all aspects of the patient's care are integrated and that there is seamless communication among providers.
Patient Engagement: Effective CCM programs prioritize patient engagement and empowerment. This involves actively involving patients in their care decisions, providing them with easy access to information and support, and addressing their social determinants of health, such as housing, transportation, and food security.
Technology Utilization: Technology plays a crucial role in enabling effective CCM. Electronic health records (EHRs), telehealth platforms, remote patient monitoring devices, and patient portals facilitate communication, data sharing, and care coordination.
Benefits of CCM:
Improved Patient Outcomes:
Reduced hospitalizations and emergency department visits
Better control of chronic conditions
Improved quality of life
Increased patient satisfaction
Reduced Healthcare Costs:
Lowering healthcare utilization can significantly reduce overall healthcare costs.
Preventing costly complications and hospitalizations.
Enhanced Provider Efficiency:
Streamlining care coordination and reducing administrative burden.
Improving communication and collaboration among providers.
Decreasing complications and effects of chronic conditions
Enabling more efficient use of provider time.
Improved Population Health:
By focusing on proactive care and addressing the needs of high-risk populations, CCM contributes to improved population health outcomes.
Eligibility for CCM
To be eligible for Medicare reimbursement for CCM services, patients must meet the following criteria:
Have two or more chronic conditions expected to last at least 12 months or until death.
Have chronic conditions that place them at significant risk of death, acute exacerbation/decompensation, or functional decline.
Have been seen by the provider within the last 12 months.
For more information on Medicare eligibility for Chronic Care Management, visit Medicare's official guidelines.

Chronic care management CPT Codes and Reimbursement
Healthcare providers can bill for CCM services using specific Current Procedural Terminology (CPT) codes. These codes vary depending on the level of service provided and the time spent by healthcare professionals.
For more on Medicare CCM Coding, visit the official CMS resource page. Additionally, be sure to check the American Academy of Family Physicians for additional coding insights.
Key CCM Codes:
99437-99439: These codes are used for basic CCM services, typically involving 20 to 60 minutes of clinical staff time per month.
99487-99490: These codes are used for complex CCM services, requiring more intensive care coordination and involving at least 60 minutes of clinical staff time per month.
99491: includes only time that’s spent personally by the billing practitioner. Clinical staff time doesn’t count toward the required reporting time threshold code
CCM Reimbursement Rates by State (Approximate)
Please Note: Reimbursement rates vary significantly based on factors such as geographic location, payer contracts, and the specific CPT codes used. This table provides a general overview and may not reflect actual reimbursement rates in all areas.
State | Average Reimbursement for CPT 99490 (Approximate) | Medicare 80% | Secondary 20% |
---|---|---|---|
Alabama | $39.27 | $46.45 | $11.61 |
Alaska | $54.60 | $62.39 | $15.60 |
Arizona | $41.01 | $47.64 | $11.91 |
Arkansas | $38.18 | $44.70 | $11.18 |
California | $43.29 - $50.04 (varies by region) | $52.46 | $13.11 |
Colorado | $42.69 | $49.44 | $12.36 |
Connecticut | $45.14 | $51.19 | $12.80 |
Delaware | $42.78 | $48.38 | $12.09 |
Florida | $41.59 - $45.44 (varies by region) | $49.54 | $12.39 |
Georgia | $39.82 - $42.18 (varies by region) | $48.53 | $12.13 |
Hawaii | $44.43 | $50.83 | $12.71 |
Idaho | $38.68 | $45.62 | $11.41 |
Illinois | $40.71 - $44.81 (varies by region) | $50.44 | $12.61 |
Indiana | $39.06 | $45.95 | $11.49 |
Iowa | $39.10 | $45.72 | $11.43 |
Kansas | $39.27 | $45.70 | $11.43 |
Kentucky | $39.19 | $45.68 | $11.42 |
Louisiana | $39.99 - $41.68 (varies by region) | $47.27 | $11.82 |
Maine | $39.53 - $41.55 (varies by region) | $48.10 | $12.03 |
Maryland | $43.24 - $45.14 (varies by region) | $51.02 | $12.76 |
Massachusetts | $43.83 - $46.62 (varies by region) | $53.44 | $13.36 |
Michigan | $40.33 - $43.16 (varies by region) | $49.29 | $12.32 |
Minnesota | $41.30 | $47.82 | $11.96 |
Mississippi | $38.17 | $44.93 | $11.23 |
Missouri | $39.45 | $47.38 | $11.84 |
Montana | $40.65 | $48.36 | $12.09 |
Nebraska | $39.27 | $45.57 | $11.39 |
Nevada | $42.06 | $48.15 | $12.04 |
New Hampshire | $42.57 | $48.94 | $12.24 |
New Jersey | $45.14 | $53.70 | $13.43 |
New Mexico | $40.38 | $46.73 | $11.68 |
New York | $44.81 | $54.57 | $13.64 |
North Carolina | $40.20 | $46.32 | $11.58 |
North Dakota | $39.27 | $47.64 | $11.91 |
Ohio | $40.05 | $46.58 | $11.64 |
Oklahoma | $38.18 | $45.82 | $11.45 |
Oregon | $41.94 | $50.40 | $12.60 |
Pennsylvania | $42.23 | $50.40 | $12.60 |
Rhode Island | $45.14 | $49.62 | $12.41 |
South Carolina | $39.82 | $46.28 | $11.57 |
South Dakota | $39.27 | $47.43 | $11.86 |
Tennessee | $39.19 | $45.50 | $11.38 |
Texas | $39.27 | $48.56 | $12.14 |
Utah | $39.27 | $46.88 | $11.72 |
Vermont | $42.57 | $47.50 | $11.87 |
Virginia | $43.24 | $47.73 | $11.93 |
Washington | $42.69 | $53.89 | $13.47 |
West Virginia | $39.19 | $46.02 | $11.50 |
Wisconsin | $40.71 | $46.45 | $11.61 |
Wyoming | $39.27 | $47.98 | $12.00 |
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Please Note: Reimbursement rates vary significantly based on factors such as geographic location/region, payer contracts, and the specific CPT codes used. This table provides a general overview and may not reflect the actual rates in all areas.
Please consult the Medicare Physician Fee Schedule for the most up-to-date and accurate reimbursement rates in your specific region.
Implementing CCM in Your Practice
Assessing Your Practice’s Readiness for CCM
Evaluate your current workflow, staffing, technology, and patient population.
Analyze existing processes for patient care and identify potential bottlenecks.
Assess the current skillset and availability of your staff.
Evaluate your current technology infrastructure, including EHR systems, telehealth capabilities, and data management systems.
Analyze your patient population to identify those who would most benefit from CCM services.