What CPT codes are used for chronic care management (CCM) visits?

Face-to-face visits use standard E/M codes (99213-99215). Non-face-to-face CCM uses: 99490 (20+ min/month clinical staff time), 99487 (60+ min complex CCM), 99489 (each additional 30 min). CCM requires ≥2 chronic conditions, care plan, and patient consent. Only one provider can bill CCM per patient per month.

What documentation is required for CCM billing (99490)?

Document: 2+ chronic conditions expected to last 12+ months, patient consent for CCM services, care plan with goals and barriers, ≥20 minutes of non-face-to-face clinical staff time, specific activities performed (care coordination, medication management, communication), and date of services. Time logs should be contemporaneous.

How should multiple chronic conditions be documented for complexity?

Document each condition with: current status (controlled, uncontrolled, stable, worsening), recent relevant data (labs, vitals), interaction with other conditions, and specific management plan. For MDM: 2 stable chronic conditions = moderate complexity (99214); chronic illness with severe exacerbation or progression = high complexity (99215).

What care coordination documentation supports billing?

Document: specialists involved in care, communications sent/received (counts toward data for MDM), care plan updates, medication reconciliation across providers, and coordination activities performed. For CCM, track time spent on care coordination activities. Document communication method and outcome of specialist coordination.

How do I document for Principal Care Management (PCM) versus CCM?

PCM (99424-99427) is for single high-risk chronic condition requiring frequent monitoring. CCM (99490) is for 2+ chronic conditions. Document: for PCM - single serious condition named, complexity justifying intensive management; for CCM - ≥2 conditions with care coordination needs. PCM can bill for less than 20 minutes; CCM requires ≥20 minutes/month.

Chronic Disease Management Template - CCM Visit Note

Primary Care — Chronic Disease Management Visit Template

Primary Care Family Medicine Updated: 11/7/2025

The Chronic Disease Management Visit Template is designed for primary care providers conducting structured visits for patients with chronic conditions such as diabetes, hypertension, heart disease, COPD, and other long-term health conditions. This template supports Medicare Chronic Care Management (CCM) billing requirements and ensures comprehensive documentation of disease status, medication management, self-management support, and care coordination. The template includes sections for chronic condition review with current status and control, medication reconciliation and adherence assessment, symptom monitoring, self-management goal setting and support, preventive care gaps identification, care coordination with specialists, patient education on disease management, and follow-up planning. This template facilitates value-based care delivery, supports quality metric reporting, ensures appropriate CCM billing, and improves chronic disease outcomes through systematic care management. Ideal for primary care practices participating in value-based care programs, practices managing high volumes of chronic disease patients, and practices billing for Medicare CCM services.

Visit Information

Visit type: Chronic Care Management (CCM) / Routine chronic disease follow-up
Chronic conditions: [List active chronic conditions]

Chronic Condition Review

For each chronic condition:

[Condition name]: Status (well-controlled / improving / stable / worsening)
Symptoms: [Current symptoms or absence of symptoms]
Control metrics: [Labs, vitals, functional status]
Complications: None / [Specify if present]

Medication Reconciliation

Current medications: [List all medications with dosages]
Adherence: Taking as prescribed / Missed doses / Barriers: [specify]
Side effects: None / [Specify if present]
Medication changes: Continue / Adjust / Add / Discontinue

Self-Management Assessment

Patient understanding: Good / Needs reinforcement
Self-monitoring: [Blood pressure, glucose, symptoms]
Lifestyle factors: Diet, exercise, smoking, alcohol
Barriers to self-management: [Identify barriers]

Preventive Care Gaps

Screening due: [Mammogram, colonoscopy, etc.]
Immunizations due: [Flu, pneumonia, etc.]
Labs due: [A1C, lipids, etc.]

Care Coordination

Specialist involvement: [List specialists and last visit dates]
Care coordination needs: [Referrals, communication with specialists]
Hospitalizations/ED visits: [Since last visit]

Assessment

1) [Chronic condition 1] — Status: [well-controlled / needs adjustment]
2) [Chronic condition 2] — Status: [as applicable]
3) [Other diagnoses]

Plan

1) Continue current management / Adjust medications: [specify]
2) Order labs/imaging: [specify]
3) Referrals: [If needed]
4) Patient education: [Disease management, medication adherence, lifestyle]
5) Care coordination: [Actions needed]
6) Follow-up: Return in [timeframe] for CCM / Routine follow-up

Patient Instructions

Self-management goals reviewed. Patient verbalized understanding. Next appointment scheduled.