Chronic Care Management

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 is clinical staff time spent on care coordination outside of a face-to-face visit. It is billed monthly, in 20-minute tiers, when the billing practitioner is supervising the work.

Who qualifies

• Patient has ≥ 2 chronic conditions documented in the medical record with active management.
• A qualifying initiating face-to-face visit (E/M, AWV, IPPE, or comparable) occurred within the prior 12 months, OR is the visit at which CCM is being initiated.
• Patient consent has been obtained (verbally or in writing) and documented.
• A comprehensive electronic care plan exists and is accessible to all care team members 24/7.
• Only one practitioner may bill CCM for a given patient in a calendar month.
• The patient is not concurrently enrolled in APCM (mutually exclusive with CCM and PCM).

Codes & when to bill them

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

• 99490First 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.
  Requirements≥ 20 minutes total clinical staff time; 2+ chronic conditions; care plan on file; consent on file.
• 99439Each additional 20 minutes of clinical staff time, per calendar month (use up to 2 add-ons).
  RequirementsAdd-on to 99490. Maximum 2 add-ons per month (covers 40-60+ min). 99491 cannot be combined.
• 99487Complex CCM — first 60 minutes of clinical staff time, per calendar month, when moderate-or-high MDM is required.
  RequirementsSubstantial revision of the care plan; moderate or high-complexity medical decision-making by the billing practitioner.
• 99489Complex CCM — each additional 30 minutes (use with 99487).
  RequirementsAdd-on to 99487 only.
• 99491First 30 minutes of CCM personally performed by the billing physician or QHCP (not staff time).
  RequirementsPractitioner's own time only. Cannot be combined with 99490 or 99437 in the same month.
• 99437Each additional 30 minutes of physician/QHCP-personally-performed CCM (use with 99491).
  RequirementsAdd-on to 99491. Maximum 2 add-ons per month.

Documentation required every cycle

Each calendar month must show:

1. Total clinical staff time spent on CCM (rounded to the minute).
2. Each encounter logged with: who performed it (name + role), start/end times, and a narrative of what was done.
3. Care plan signed by the billing practitioner; reviewed and updated as the patient's status changes.
4. Two or more chronic conditions documented as the basis for eligibility, each with the ICD-10 code.
5. General supervision by the billing practitioner attested at sign-off.
6. Patient consent on file, with version, date, and capture method.

What's new in CY 2026

CY 2026 retains the structure of 99490 + 99439 add-ons. Complex CCM (99487/99489) thresholds unchanged. The 2026 PFS continues to reimburse the patient consent and care-plan creation work under the initiating visit; no separate G-code for initiating CCM in 2026.

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.