Understanding Chronic Care Management

Chronic Care Management (CCM) is defined as the non-face-to-face services provided to Medicare beneficiaries who have multiple (two or more), significant chronic conditions.  A Chronic Condition as defined by Medicare is a continuous or episodic health condition that is 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 provide guidance as to what diagnoses will meet this definition.    In addition to office visits and other face-to- face encounters (billed separately), these services include communication with the patient and other treating health professionals for care coordination (both electronically and by phone), medication management, and being accessible 24 hours a day to patients and any care providers (physicians or other clinical staff). The creation and revision of electronic care plans is also a key component of CCM.  Comprehensive Care Plan (CCP) is an electronic summary of the physical, mental, cognitive, psychosocial, functional, and environmental assessments, a record of all recommended preventive care services, medication reconciliation with review of adherence and potential interactions and oversight of patient self-management of medications, an inventory of clinicians, resources, and supports specific to the patients, including how the services of agencies or specialists unconnected to the designated physician’s practice will be coordinated. Including assurance of care appropriate for patient’s choices and values.



The designated CCM clinician must establish, implement, revise, or monitor and manage an electronic care plan that addresses the physical, mental, cognitive, psychosocial, functional and environmental needs of the patient as well as maintain an inventory of resources and support that the patient needs.   CMS codes can only be billed by a physician (MD, DO), advanced practice registered nurse (NP), clinical nurse specialists (CNS), or physician assistant (PA).

Only one clinician can bill for any particular patient.  These services are generally intended for use by the clinician who is providing the majority of the care coordination services.  This is most often the primary care provider.

Certain specialties may be able to provide the services needed to qualify to bill the CCM codes, but never in the same month as the primary care physician.  Therefore, it is important that the patients understand only one of their physicians will be able to bill for CCM services.

To count the time towards the 20-minutes of non-face-to-face time, the care must be “contact initiated.” This could be patient-doctor, patient-nurse, doctor-doctor, pharmacy- doctor, lab-doctor, or other contact regarding or by the patient via phone or electronic communication. General planning time or care coordination doesn’t count unless it is initiated based on a contact and/or results in a patient or patient-related contact.

Clinical staff – Licensed clinical staff members (including APRN, PA, RN, LSCSW, LPN, clinical pharmacists, and “medical technical assistants” or CMAs) who are directly employed by the clinician (or the clinician’s practice) or a contracted third party and whose CCM services are generally supervised by the clinician, whether provided during or after hours. Thus the “incident to” rules do not necessarily require that the clinician be on the premises providing direct supervision.

Certified CCM technology –  CCM codes must be provided by a certified EHR that satisfies either the 2011 or 2014 edition of the certification criteria for the EHR Incentive Programs with the following core technology capabilities: structured recording of demographics, problems, medications, and medication allergies and creation of a summary of care record that can be maintained and accessed at any time.

Copayments (coinsurance and deductibles) DO apply.

Document patient consent, if they declined to participate, or indicated participation elsewhere (and if so, with whom).

Document 20 minutes of non-face-to-face clinical staff time. Each practice will need to develop its own consistent system of documentation based on its unique physical, staffing, and EHR configuration. Consideration should include documentation of care provided by both internal and external (such as for call coverage) individuals, who and how care will be documented in the record, and how to document time spent doing different aspects of care and care coordination. It is quite possible, that there will not be a CCM code billed for every patient every month, some months may not generate 20 minutes of care coordination.

CMS recognizes clinical  staff as licensed clinical staff members (including APRN, PA, RN, LSCSW, LPN, clinical pharmacists, and “medical technical assistants” or CMAs) who are directly employed by the clinician (or the clinician’s practice) or a contracted third party and whose CCM services are generally supervised by the clinician, whether provided during or after hours. Thus the “incident to” rules do not necessarily require that the clinician be on the premises providing direct supervision.

If after hours care is provided by a clinician who is not part of the practice, such as for call coverage, that individual must have access to the electronic care plan (other than by facsimile). The care plan may be accessed via a secure portal, a hospital platform, a web-based care management application, a health information exchange, or an EHR to EHR interface.

Services can be provided “incident-to” the designated clinician if the CCM services are provided by licensed clinical staff employed by the clinician or practice who are under the general, not necessarily the direct, supervision of the designated clinician. The normal “incident-to” documentation requirements apply.

Contracted clinicians, such as covering clinicians or locum tenens, count as long as they have access 24/7 to the patient’s electronic record and are under the general supervision of the CCM physician or “eligible practitioner.”

If you have 2 or more serious chronic conditions that are expected to last at least a year, Medicare may pay for a health care professional’s help to manage those conditions.

Chronic care management offers additional help managing conditions like arthritis, asthma, diabetes, hypertension, heart disease, and osteoporosis.

Services may include:

  • At least 20 minutes per month of chronic care management services
  • Personalized help from a dedicated health care professional who will work with you to create a care plan
  • based on your needs and goals
  • Care coordinated between your doctor, pharmacy, specialists, testing centers, hospitals, and other services
  • Phone check-ins between visits to keep you on track
  • Emergency access to a health care professional, 24 hours a day, 7 days a week
  • Expert help with setting and meeting your health goals


Who’s eligible?

All people with Part B are covered. To get started, ask your health care professionals if they provide chronic care management services.

Your costs in Original Medicare

You may pay a monthly fee, and the Part B deductible and coinsurance apply. If you have supplemental insurance, or have both Medicare and Medicaid, it may help cover the monthly fee.