Better Capture CCM to Get Paid for the Work
A workflow adjustment can pull in the chronic care management revenue practices already earn. Independent practices talk about chronic care management (CCM) as if the problem were the rate; however, capture is the problem. The calendar year (CY) 2026 Medicare Physician Fee Schedule still pays the full CCM family, and the Centers for Medicare & Medicaid Services (CMS) kept time-based care management out of its new efficiency adjustment to work relative value units (RVUs). What fails is capture: the consent, the clock, the care plan, or the claim. Understand Eligibility, Initiating Visit, and Consent Medicare pays CCM for patients with two or more chronic conditions expected to last at least 12 months or until death that place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline. CMS’ illustrative examples include diabetes, hypertension, chronic obstructive pulmonary disorder (COPD), cardiovascular disease, depression, and arthritis. For a new patient, or one the billing practitioner has not seen within the previous year, CMS requires an initiating visit before CCM starts: a comprehensive face-to-face evaluation and management (E/M) visit, an annual wellness visit (AWV), or an initial preventive physical exam (IPPE). The face-to-face visit involved in transitional care management (TCM) also qualifies. You would bill that visit on its own, and the provider must discuss CCM during it. When the billing practitioner personally performs extensive assessment and care planning beyond the usual effort of the initiating visit and the CCM codes, you may add HCPCS code G0506 (Comprehensive assessment of and care planning for patients requiring chronic care management services (list separately in addition to primary monthly care management service)) once; do not count that work again toward CCM minutes. Get written or verbal consent before CCM begins, and document the five CMS points: CCM is available; cost sharing may apply; only one practitioner can bill CCM in a calendar month; the patient may stop at any time, effective at month’s end; and whether the patient accepted or declined. Consent is needed just once unless the patient switches practitioners. Consider Time, Complexity, and 3 Billing Lanes CCM is billed per calendar month in one of three mutually exclusive lanes, which are differentiated by the staff member providing the services, the complexity of the care, the number of a patient’s chronic conditions, medical decision making (MDM), and time, among other elements. For clinical staff, you can capture noncomplex CCM with certain CCM-specific codes, including the following: When the practitioner performs CCM, you’ll choose between the following codes: Complex CCM encounters incorporate more criteria; report these services with the following codes: CMS assigns general supervision to 99487, +99489, 99490, and +99439; the billing practitioner need not be physically present, and the practitioner’s own time may count toward those codes when it is not used to report 99491. Time counted toward CCM cannot count toward any other billed code. Observe Overlap Rules You may report CCM during a transitional care management (TCM) 30-day period when medically necessary. For example, you can report 99495 (Transitional care management services with the following required elements: communication [direct contact, telephone, electronic] with the patient and/or caregiver within 2 business days of discharge; medical decision making of at least moderate complexity during the service period; face-to-face visit within 14 calendar days of discharge) or 99496 (Transitional care management services with the following required elements: communication [direct contact, telephone, electronic] with the patient and/or caregiver within 2 business days of discharge; medical decision making of high complexity during the service period; face-to-face visit within 7 calendar days of discharge) as long as minutes are not counted twice. You may bill either remote physiologic monitoring or remote therapeutic monitoring with CCM, but not both. The same practitioner cannot bill CCM and principal care management (PCM) codes 99424-+99427 (Principal care management services …) for the same patient in the same month; a different practitioner may bill PCM for a different condition, with a separate care plan. The same rule applies to advanced primary care management (APCM) codes G0556-G0558 (Advanced primary care management services …). The practitioner billing APCM cannot also bill CCM for that patient that month, but a different practitioner may when medically necessary. CCM cannot be billed in the same service period as some other services, like home health and hospice codes G0181-G0182 (Physician or other qualified health care professional supervision of a patient receiving Medicare-covered services provided by a participating … home health … hospice … agency …); or certain end-stage renal disease (ESRD) services, such as 90951-90970 (End-stage renal disease [ESRD] related services …). You cannot report complex CCM and prolonged E/M services in the same month. Line up Documentation and the Monthly Close A monthly minute total without a care plan is not CCM. Maintain a patient-centered, electronic comprehensive care plan. CMS describes its typical elements, among them a problem list, measurable treatment goals, planned interventions, medical management, and periodic review, while noting they are not a strict billing checklist. Make the plan available inside and outside the practice and give the patient or caregiver a copy when necessary. Each time entry should name the staff member, date, minutes, and activity. According to CPT® care management guidelines, a 10-minute huddle between two staff members is 10 minutes of CCM time, not 20. Before submitting a claim, confirm eligibility, consent, the initiating visit (when required), the correct “lane” and minute threshold, and that no minute is already counted toward another billed service. Care managers can log time; the billing practitioner attests to supervision and, for complex CCM, MDM. For 99490, +99439, 99491, and +99437, CMS allows the claim to go out once the threshold is reached, using that date as the date of service, provided medically necessary CCM continues through the month. Complex CCM (99487, 99489) is the exception: Report it at month’s end, because MDM is judged across the whole period. Never bill 99490 for 12 documented minutes, 99490 with 99491, or 2 units of 99490. Problems may arise, like a missing initiating visit, undocumented consent, double-counted time, mixed “lanes,” another practitioner already billing CCM that month, or a static problem list offered as a care plan. Check out This 90-Day Practice Checklist Consider implementing these practices into your workflow to better capture CCM services: Capturing CCM requires work on top of what the team already does between visits, but the payoff can involve more comprehensive patient care and reimbursement for that work. J. Madison Gardner, President, AMS Solutions Inc. 
