Billing for Chronic Care Management

** UPDATE FOR 2017 **

An estimated 117 million adults have one or more chronic health conditions, and one in four adults have two or more chronic health conditions. Chronic disease is prevalent among Medicare beneficiaries, with most beneficiaries having multiple chronic conditions, which increases the risk for poor health outcomes such as mortality and functional limitations.  The Centers for Medicare & Medicaid Services (CMS) recognizes chronic care management (CCM) as one of the critical components of primary care that contributes to better health and care for individuals, and holds promise for reducing overall health care costs.

Beginning January 1, 2017, CMS adopted 3 additional billing codes (G0506, 99487, 99489) to recognize the initiation of CCM and a new category called Complex CCM.  In order to assist with understanding CCM, CMS has created a Healthcare Professional Toolkit, as well as other resources available at their CCM Digital Hub.   For all CCM codes, simplified and reduced billing and documentation rules, especially around patient consent and use of electronic technology have been put in place.


Source: Medical Group Management Association

As part of an ongoing effort to enhance care coordination for Medicare beneficiaries, the Centers for Medicare & Medicaid Services (CMS) established a non-face-to-face chronic care management (CCM) service as a Medicare benefit effective Jan. 1, 2015. CMS finalized the use of CPT code 99490 for Medicare CCM. This service may be billed as a complement to face-to-face services such as office visits.

Patients eligible for CCM services include those with multiple chronic conditions that are expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation or functional decline. CMS does not specify which diagnoses are considered eligible chronic conditions.

Chronic care management services require at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, for a patient that meets the following required elements:


  • Multiple (two or more) chronic conditions that are expected to last at least 12 months, or until the death of the patient;
  • Chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation or functional decline; and
  • A comprehensive care plan that has been established, implemented, revised or monitored.


Before a practitioner can furnish or bill for CCM services, eligible beneficiaries must be informed about the availability of these services, how they are accessed and how their information will be shared with other providers involved in their care. Practices must obtain the beneficiary’s written agreement to furnish CCM services, including the beneficiary’s authorization for the electronic communication of his or her medical information with other treating providers as part of care coordination.


Additionally, as part of obtaining beneficiary consent a practice must:

  • Identify the name of the provider who will be furnishing the CCM services and inform the beneficiary that only one practitioner can furnish and be paid for these services during a calendar month;
  • Inform the beneficiary that cost-sharing applies to CCM services even though they are not delivered face-to-face;
  • Inform the beneficiary of the right to stop the CCM services at any time (effective at the end of a calendar month) as well as the effect of a revocation of the agreement to receive CCM services;
  • Provide a written or electronic copy of the comprehensive care plan to the beneficiary, which must be documented in the patient’s electronic medical record; and
  • Document in the beneficiary’s medical record that all elements of the CCM service were explained and offered to the beneficiary, and note the beneficiary’s decision to accept or decline the service.


As with most Medicare services (except those designated as preventive services), 20% beneficiary cost-sharing applies, which, based on the average national payment, equates to $8.52 coinsurance per calendar month. Beneficiaries may also be responsible for a deductible payment, if appropriate.


CMS suggests that practices may want to consider explaining that although cost-sharing applies for CCM services, they may help the beneficiary avoid the need for more costly face-to-face services that entail greater cost-sharing. CMS does not specify how frequently beneficiary consent must be obtained. Practices may want to consider establishing a process for periodically obtaining this consent. For example, once a year or after there has been a break of more than a few months of furnishing CCM services.