Chronic Care

Chronic Care Management

Q: Who qualifies for Chronic Care Management (CCM)?

Two or more chronic conditions on the signed care plan; the billing practitioner records Medicare's definition for each when signing the month. The initiating visit with the billing practitioner — an E/M visit (not 99211), the Annual Wellness Visit, the Welcome to Medicare visit or a TCM face-to-face visit where CCM was discussed — or an established patient the practitioner saw in the 12 months before, recorded on the enrollment. Consent to CCM from the billing practitioner (verbal or written), with the moment the patient agreed; time counts from then. A comprehensive electronic care plan, signed by the practitioner, with a copy to the patient, and 24/7 access to the care team. Only one practitioner bills CCM for a patient in a calendar month; the same practitioner never bills PCM beside it, and willowbridge never bills APCM and CCM for the same patient in the same month. A missing piece holds the month until it is recorded; nothing logged is lost.

Q: Which codes does willowbridge bill for CCM, and when?

Bill 99490 once the month reaches 20 counted minutes of clinical staff and practitioner time together, then 99439 at 40 and again at 60 (two at most). When 30 minutes are the practitioner's own, 99491 is a candidate (+ 99437 at 60 and 90 of their own); a complex month — moderate or high medical decision making recorded by the practitioner — can bill 99487 at 60 minutes and 99489 for each further 30, up to four. willowbridge bills the lineup that describes the month and, where two do, the one Medicare pays more for, and prints why on the billing note.

CCM Period: Calendar month Source: CMS-1832-F (CY 2026 PFS Final Rule)

What it is

Chronic Care Management (CCM) is a Medicare Part B benefit for patients with two or more chronic conditions expected to last at least 12 months (or until the patient's death) that place the patient at significant risk of death, acute exacerbation, decompensation, or functional decline.

CCM pays for non-face-to-face care management under a comprehensive care plan: time by the practice's clinical staff under the billing practitioner's general supervision, together with the practitioner's own time. It is billed once per calendar month, by one practitioner, and each claim is dated to the day its minutes were reached (complex CCM to the month's last day).

Who qualifies

Two or more chronic conditions on the signed care plan; the billing practitioner records Medicare's definition for each when signing the month.
The initiating visit with the billing practitioner — an E/M visit (not 99211), the Annual Wellness Visit, the Welcome to Medicare visit or a TCM face-to-face visit where CCM was discussed — or an established patient the practitioner saw in the 12 months before, recorded on the enrollment.
Consent to CCM from the billing practitioner (verbal or written), with the moment the patient agreed; time counts from then.
A comprehensive electronic care plan, signed by the practitioner, with a copy to the patient, and 24/7 access to the care team.
Only one practitioner bills CCM for a patient in a calendar month; the same practitioner never bills PCM beside it, and willowbridge never bills APCM and CCM for the same patient in the same month.
A missing piece holds the month until it is recorded; nothing logged is lost.

Codes & when to bill them

How the minutes add upBill 99490 once the month reaches 20 counted minutes of clinical staff and practitioner time together, then 99439 at 40 and again at 60 (two at most). When 30 minutes are the practitioner's own, 99491 is a candidate (+ 99437 at 60 and 90 of their own); a complex month — moderate or high medical decision making recorded by the practitioner — can bill 99487 at 60 minutes and 99489 for each further 30, up to four. willowbridge bills the lineup that describes the month and, where two do, the one Medicare pays more for, and prints why on the billing note.

Each billable code, with the requirements that must be on file to bill it.

99490First 20 minutes of clinical staff time (with the billing practitioner's own time), per calendar month.

Requirements20 or more counted minutes; two or more chronic conditions; a signed care plan; the consent for this practitioner; the initiating visit.
99439Each additional 20 minutes of clinical staff time, per calendar month.

RequirementsAdd-on to 99490 on the same claim and date; up to two (40 and 60 minutes).
99491First 30 minutes of CCM personally performed by the billing physician or qualified practitioner.

RequirementsOnly the practitioner's own minutes count; staff entries are listed and not counted.
99437Each additional 30 minutes personally performed by the billing practitioner (use with 99491).

RequirementsAdd-on to 99491; up to two (60 and 90 minutes).
99487Complex CCM — first 60 minutes of clinical staff and practitioner time, with moderate or high medical decision making.

RequirementsThe MDM is the billing practitioner's own, recorded for the month; dated to the month's last day.
99489Complex CCM — each additional 30 minutes (use with 99487).

RequirementsAdd-on to 99487; up to four (to 180 minutes).

Documentation required every cycle

Each calendar month's billing note prints the month's frozen record:

The codes and why, the counted minutes by role, and every logged entry that did not count, with why.
The date of service and why — the day the 20th counted minute (or the last billed add-on) was reached.
Each time entry — who, when, how long, the activity and a note.
The consent — when the patient agreed, how, who captured it, and the practitioner it names — and the initiating visit.
The chronic conditions with the practitioner's determination, and the care-plan version the month froze on.
The practitioner's signature: general supervision for the staff codes, their own time on 99491, the MDM on complex CCM.

What's new in CY 2026

CY 2026: the CCM codes and descriptors are unchanged, and CCM is exempt from the 2026 efficiency adjustment. G0506, the add-on for extensive care planning at the initiating visit, is billed by your practice on that visit's own claim; willowbridge records the initiating visit and reminds the practitioner, and never files G0506.

Built-in patient consentwillowbridge exclusive

Every program ships with compliant, CY-2026 patient consent language — read verbatim into the in-app consent capture flow, captured with date + modality, and version-pinned to each claim, so the consent on file always matches the consent that was billed. No more chasing signatures or re-papering when the rule changes.

Common questions

Who qualifies for Chronic Care Management (CCM)?

Two or more chronic conditions on the signed care plan; the billing practitioner records Medicare's definition for each when signing the month. The initiating visit with the billing practitioner — an E/M visit (not 99211), the Annual Wellness Visit, the Welcome to Medicare visit or a TCM face-to-face visit where CCM was discussed — or an established patient the practitioner saw in the 12 months before, recorded on the enrollment. Consent to CCM from the billing practitioner (verbal or written), with the moment the patient agreed; time counts from then. A comprehensive electronic care plan, signed by the practitioner, with a copy to the patient, and 24/7 access to the care team. Only one practitioner bills CCM for a patient in a calendar month; the same practitioner never bills PCM beside it, and willowbridge never bills APCM and CCM for the same patient in the same month. A missing piece holds the month until it is recorded; nothing logged is lost.

Which codes does willowbridge bill for CCM, and when?

Bill 99490 once the month reaches 20 counted minutes of clinical staff and practitioner time together, then 99439 at 40 and again at 60 (two at most). When 30 minutes are the practitioner's own, 99491 is a candidate (+ 99437 at 60 and 90 of their own); a complex month — moderate or high medical decision making recorded by the practitioner — can bill 99487 at 60 minutes and 99489 for each further 30, up to four. willowbridge bills the lineup that describes the month and, where two do, the one Medicare pays more for, and prints why on the billing note.

What changed for CCM in CY 2026?

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