Chronic & Principal Care Management (CCM / PCM)
Care plans, monthly outreach and documentation built for review
Chronic Care Management (CCM) is Medicare's time-based monthly service for patients with two or more chronic conditions; Principal Care Management (PCM) covers patients with a single complex chronic condition. We design, launch and run the program around them: consent, condition-specific care plans, monthly touchpoints, care-gap work and the documentation behind every claim.
- CCM 99490 · 99439 · 99491 · 99437 · 99487 · 99489
- PCM 99424–99427
- Minutes never carry over
Who it's for
Built for the organizations that carry this work
Practices starting a CCM program
Primary care practices with Medicare patients who have two or more chronic conditions, and no structured workflow yet for consent, care plans and monthly time.
Practices with a program that needs tightening
Teams whose documentation, minute logs or care plans would not hold up to a chart review, or whose staff were never formally onboarded.
Practices weighing CCM against APCM
For the same patient, month and practitioner it is one or the other. We set up the monthly sort so each patient lands in the program that matches the work delivered.
Specialists managing chronic disease
An outside specialist may bill CCM while the patient's primary care practitioner bills APCM, because they are different practitioners.
What we do
What you receive
- 01
Onboarding and documentation workflow manual
Six areas: consenting, documentation review, clinical documentation, creating the care plan, identifying care gaps and closing care gaps.
- 02
Condition-specific care plan library
Care plans for 14 chronic conditions, plus prefilled plans for common two-condition pairs such as hypertension with diabetes or heart failure with diabetes.
- 03
Documentation templates
Consent and eligibility worksheet, initiating progress note, comprehensive care plan, monthly care coordination summary and a care-gap closure log.
- 04
Two-day staff training
Day 1 runs from eligibility to a compliant initial encounter; Day 2 covers care plan development, gap management and audit readiness, ending with a competency sign-off.
- 05
Care coordinator hiring support
An interview and screening guide for RN care coordinators, so the role is filled against the work the program actually requires.
- 06
Monthly program sort and operations
A month-end routine that assigns one program per patient (CCM, PCM, APCM or TCM) with a claim edit and an audit file, run by your team with our oversight or operated with your staff.
How it works
The six areas of a CCM workflow
The same sequence your staff learns in training and follows every month.
- 1
Consenting
Confirm eligibility, explain the service and cost-sharing, and document consent before the first billed month.
- 2
Documentation review
Review the record so the chronic conditions, history and current plan of care are complete before outreach begins.
- 3
Clinical documentation
Initiating visit and progress notes that support the conditions and the time billed.
- 4
Creating the care plan
A comprehensive, condition-specific care plan the patient receives a copy of.
- 5
Identifying care gaps
Open screenings, uncontrolled results and missed follow-up surfaced during monthly contacts.
- 6
Closing care gaps
Orders, referrals and follow-up tracked to closure in a care-gap log.
Program facts
Codes, requirements and rules
Medicare fee-for-service rules for CY 2026.
CCM codes
99490
- When it applies
- Clinical staff time, first 20 minutes per month
+99439
- When it applies
- Each additional 20 minutes (maximum two per month)
99491
- When it applies
- Physician or qualified health professional personally, first 30 minutes
+99437
- When it applies
- Each additional 30 minutes (physician or QHP)
99487
- When it applies
- Complex CCM, first 60 minutes, moderate-to-high medical decision making
+99489
- When it applies
- Each additional 30 minutes, complex CCM
+G0506
- When it applies
- Extensive care planning at the initiating visit
99424–99427
- When it applies
- Principal Care Management (PCM): care management focused on a single complex chronic condition
CCM claim rules
- Bill only after the minute threshold is met and documented.
- Minutes never carry over to the next month.
- List two or more chronic conditions (ICD-10) on the claim.
- Use place of service 11 (office) for the non-facility rate.
- Keep CCM consent on file; it does not cover APCM.
Which program this month?
45 minutes of CCM documented
- Bill
- 99490 + 99439
- Why
- The CCM add-on may pay more than APCM Level 2 (G0557)
2+ chronic conditions, only 12 minutes of care management
- Bill
- G0557
- Why
- CCM pays nothing under 20 minutes
QMB with 2+ chronic conditions
- Bill
- G0558
- Why
- Highest APCM level; no patient cost-share
0–1 chronic conditions
- Bill
- G0556
- Why
- Not CCM-eligible
Discharged mid-month, TCM contact made
- Bill
- 99495 / 99496
- Why
- APCM resumes the next month
Bill after month-end so a mid-month discharge can still go to TCM. A patient moving from CCM to APCM needs a new APCM consent.
Conditions in the care plan library
Cardiovascular and metabolic
- Hypertension
- Type 2 diabetes
- Hyperlipidemia
- Atrial fibrillation
- Coronary artery disease
- Heart failure
Pulmonary and neurological
- COPD
- Asthma
- Stroke
- Dementia
- Multiple sclerosis
Musculoskeletal, oncology, mental health
- Osteoarthritis
- Rheumatoid arthritis
- Osteoporosis
- Cancer
- Major depressive disorder
- Bipolar disorder
- Schizophrenia
FAQs
Common questions
Do unused minutes carry over to the next month?
No. Minutes never carry over, and a CCM code is billed only after its threshold is met and documented in that month.
Can we bill CCM and APCM for the same patient in the same month?
Not by the same practitioner. For the same patient, calendar month and billing practitioner it is APCM or CCM, never both, because APCM already bundles CCM, PCM and TCM.
Can a specialist bill CCM while the primary care practitioner bills APCM?
Yes. Different practitioners may both bill: for example, the PCP bills APCM while an outside nephrologist bills CCM for the same patient.
Does a CCM consent cover APCM?
No. A patient moving from CCM to APCM needs a new APCM consent, documented before the first APCM month is billed.
When does CCM make more sense than APCM?
For patients who consistently receive 40 or more minutes of care management a month, CCM add-on codes can exceed the APCM Level 2 rate, so model both. Patients who sometimes miss the 20-minute threshold are usually better placed in APCM, which pays every month.
What has to be on the claim?
Two or more chronic conditions (ICD-10), the code that matches the documented time, and place of service 11 for the office (non-facility) rate. The consent and minute log stay in the record.
Ready to simplify the complex?
Let’s look at your program together.
A consultation is a working conversation about your panel, payers and EHR, and whether this service fits. Please do not send patient information.
Related services
Advanced Primary Care Management (APCM)
G0556–G0558 monthly care management, levels by complexity.
Learn moreRemote Monitoring (RPM, RTM + CGM)
Device programs for hypertension, heart failure and diabetes.
Learn morePractice Transformation & Quality Improvement
HEDIS and Star measures, care gap closure, AWV campaigns and care team redesign.
Learn more