Medically Reviewed by Nayana Ambardekar, MD on June 04, 2024
Written by Alyssa AndersonChronic care management (CCM) is a billable Medicare service that’s meant to improve the lives of both patients and physicians.
You qualify for CCM services if you have Medicare and two or more chronic conditions. The conditions need to last anywhere from 12 months to the rest of your life for you to be eligible.
The goal of CCM services is to provide coverage for the many non-face-to-face interactions that are needed to optimally manage multiple chronic conditions.
A chronic condition is a long-term medical disease or disorder. These conditions aren’t easily cured and require in-depth care. This can be complicated if you have multiple chronic conditions to manage.
You need to be diagnosed with at least two chronic conditions to qualify for CCM. An example chronic care management diagnosis list includes:
This list is not exhaustive. There are many additional conditions that qualify you for CCM. Based on your condition, your doctor or medical staff should know whether or not you qualify for CCM services.
Chronic care management services are a specific Medicare Part B benefit. They’re intended to include all of the not-in-person work behind the medical decisions in complex chronic cases.
The overall goal of CCM is to promote your health while reducing costs. If you qualify for CCM services, then your medical team will be able to bill Medicare for a wide range of additional tasks that benefit you. One of the most reassuring benefits is that you should be able to reach a physician or other member of your medical team 24 hours a day, seven days a week to discuss any urgent needs.
Other CCM services can include:
CCM services can either be simple or complex. Complex services are billed differently. A service counts as complex if, for example, it involves difficult medical decisions. Only one of your providers can bill Medicare for CCM services during any given month.
You cannot begin receiving CCM services until you’ve had an initial visit. This must occur face-to-face, but you don’t need to make a special appointment just to discuss CCM services. An initial visit can occur as part of an already-scheduled service, including:
For your in-person visit to count as an initial visit, your doctor must discuss CCM services with you. Your doctor should get written or verbal consent to include you in CCM services because you’re responsible for part of the bill.
It’s important to note that a doctor only needs a patient's consent one time to bill for these services.
You can stop CCM services whenever you want to; you just have to talk to your medical team.
Following your initial visit, your doctor or health care provider should draw up a comprehensive care plan that’s specifically focused on you and your needs. This process could require an additional in-person visit to complete.
Details that could be part of your care plan include:
Since CCM is a Medicare billable service, only qualified providers can include CCM services in their monthly billing. In order to bill for these services, Medicare requires that all activities are supervised by a:
This means that you can’t bill Medicare for CCM if your organization only employs registered nurses. However, your organization could find a qualified supervisor while still serving as the medical provider.
Supervisors do not need to be physically present when a CCM service is being provided, but it must be done under their general instruction and guidance.
It’s important to note that whoever is providing the service must be a member of the clinical care team, not on the administrative staff.
States may have their own regulations about who can and cannot provide CCM services. These are not always identical to Medicare’s requirements.
Since chronic care management services are a Medicare Part B benefit, only 80 percent of these services are covered by Medicare. This means that you’re responsible for 20 percent of the total CCM bill.
People with Medigap or who are covered by both Medicare and Medicaid will likely not have to pay any copay. Instead, your medical team should charge the additional 20 percent to the agency that provides your added coverage.
There are five codes that describe the ways that chronic care services are billed to Medicare.
These chronic care management codes include the CPT codes:
Principal care management (PCM) is a newer Medicare service that began in 2020. It’s meant to fill in some of the gaps left by CCM.
This service is specifically for people who only have a single chronic condition but still need their medical team to provide complex and coordinated care. It also applies to someone with multiple chronic conditions whose medical team needs to focus on one high-risk diagnosis.
PCM is billed with different codes than CCM.
