What are the requirements for billing Medicare CCM (99490)?

CCM requires: patient with 2+ chronic conditions expected to last at least 12 months placing them at significant risk, documented patient consent for CCM services, at least 20 minutes of non-face-to-face care management time by clinical staff per calendar month, and an established care plan. Time must be documented specifically. Initial consent can be obtained at an office visit.

What is the difference between CCM codes 99490, 99487, and 99489?

99490: 20+ minutes of clinical staff time per month (basic CCM). 99487: 60+ minutes of clinical staff time for complex CCM. 99489: add-on for each additional 30 minutes beyond 99487. Complex CCM (99487) applies when patients require substantial revision of care plan, coordination with multiple specialists, or complex medication management.

What activities count toward CCM time?

Billable activities include: care plan development/revision, medication reconciliation, communication with patient/caregiver (phone, portal), coordination with specialists and other providers, ordering and reviewing tests, arranging community resources, and medication management. Face-to-face time does NOT count toward CCM. Document specific activities and time spent.

How do I document CCM services appropriately?

Document: date of service, chronic conditions addressed (must be 2+), specific care management activities performed, time spent on each activity (cumulative must be ≥20 minutes), staff member providing service, and communication method. The total time must be clinical staff time, not physician time. Keep contemporaneous time logs.

Can CCM be billed in the same month as other care management services?

CCM cannot be billed with other care management services in the same month: TCM (99495-99496), Psychiatric Collaborative Care (99492-99494), or certain other CMIT services. It can be billed with face-to-face E/M visits. Only one CCM billing per patient per month, regardless of how many providers contribute to care management.

Chronic Care Management Note Template - CCM Documentation

Internal Medicine — Chronic Care Management Note Template

Internal Medicine Internal Medicine Updated: 11/7/2025

The Chronic Care Management Note Template is designed for primary care providers and internists documenting non-face-to-face care management services for patients with multiple chronic conditions. This template supports Medicare CCM billing (CPT 99490, 99487, 99489) and documents care coordination activities, medication management, patient communication, and care plan updates. The template includes sections for care management activities performed, medication reconciliation and management, patient communication and education, care coordination with specialists, preventive care gaps addressed, care plan updates, time spent on care management, and documentation of 20+ minutes of non-face-to-face time. This template ensures appropriate CCM billing, supports value-based care delivery, facilitates care coordination, and improves chronic disease outcomes through systematic care management. Ideal for primary care practices billing for Medicare CCM, practices managing high volumes of chronic disease patients, and practices participating in value-based care programs.

CCM Note

Date: [Date]
Patient: [Name, DOB]
Chronic conditions: [List 2+ chronic conditions]
Time spent: [X] minutes (must be 20+ for billing)

Care Management Activities

Medication management: [Review, adjustments, adherence]
Patient communication: [Phone call, portal message, etc.]
Care coordination: [With specialists, other providers]
Preventive care: [Screening reminders, immunizations]
Care plan: [Updates to care plan]

Medication Management

Medications reviewed: [List]
Changes: [Adjustments made]
Adherence: [Assessment]
Barriers: [If any]

Patient Communication

Method: [Phone, portal, etc.]
Topics: [What was discussed]
Patient response: [Understanding, concerns]

Care Coordination

Specialist communication: [If coordinated]
Test results: [Follow-up on results]
Referrals: [If made]

Preventive Care

Gaps identified: [Screening, immunizations due]
Actions: [Scheduled, ordered]

Care Plan Updates

[Updates to patient's care plan]

Assessment

CCM services provided: [Summary]
Patient status: [Overall assessment]

Plan

1) Continue CCM services
2) Follow-up: [Next CCM contact or face-to-face visit]
3) Care coordination: [Actions needed]

Documentation

Total time: [X] minutes
Billing code: [99490 / 99487 / 99489 as applicable]