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CCM Frequently Asked Questions

Chronic care management (CCM) is a healthcare service designed to help individuals with 2+ chronic conditions manage their health and improve their quality of life. It involves developing a personalized care plan, coordinating care with multiple healthcare providers, monitoring progress, and providing ongoing support and education.

Examples of chronic conditions include, but are not limited to, the following: 

  • Alzheimer’s disease and related dementia 
  • Arthritis (osteoarthritis and rheumatoid)
  • Asthma 
  • Atrial fibrillation 
  • Autism spectrum disorders 
  • Cancer 
  • Cardiovascular Disease
  • Chronic Obstructive Pulmonary Disease 
  • Depression 
  • Diabetes 
  • Hypertension 
  • Infectious diseases such as HIV/AIDS
Our chronic care management services start with a comprehensive assessment of our client's health and medical history. From there, we designate a healthcare professional who works closely with our patients to develop a personalized care plan that includes ongoing monitoring, medication management, and support from our team of healthcare professionals.

Activities that count towards CCM include:

  • Phone calls and patient questions 
  • Medication refills and adjustments 
  • Scheduling, referrals, and prior authorizations 
  • Care planning and care coordination


  • CPT 99490 – Chronic Care Management Services
  • HCPCS G0511 – General Care Management Services (for FQHCs/RHCs)
  • HCPCS G0506 – Comprehensive Assessment & Care Planning
  • CPT 99439 – non-complex CCM Add-on (New in 2021. Previously G2058)
  • CPT 99487 – Complex Chronic Care Management Services
  • CPT 99489 – Complex CCM Add-on
  • CPT 99491 – Physician-provided CCM
Yes, Care management services can be billed either alone or on a claim with an RHC or FQHC billable visit.
Improved health outcomes, better medication management, reduced healthcare costs, and increased access to healthcare resources and support are just a few benefits.
Any patient with two or more chronic diseases is eligible for CCM. Medicare, Medicare Advantage and Commercial Insurance. For commercial insurance kindly check with patients insurance provider to check the eligibility.
At 2C Health, we are committed to providing our clients with the highest quality chronic care management services. Our team of healthcare professionals has extensive experience in managing chronic conditions, and we work closely with each of our clients to develop a personalized care plan that meets their unique needs and goals. We are dedicated to staying up-to-date with the latest advances in healthcare, and we use technology and data analytics to improve our clients' outcomes and reduce healthcare costs.

Clinical staff will provide CCM services incident to the services of the billing physician (or other appropriate practitioner who can be a physician assistant, nurse practitioner, clinical nurse specialist or certified nurse midwife). Time spent by clinical staff may only be counted if Medicare’s “incident to” rules are met such as supervision, applicable State law, licensure and scope of practice. If the billing physician (or other appropriate billing practitioner) provides CCM services directly, that time counts towards the 20 minute minimum time. Of course, other staff may help facilitate CCM services, but only time spent by clinical staff may be counted towards the 20 minute minimum time.

CPT defines a clinical staff member as “a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specified professional service; but who does not individually report that professional service.”

The Centers for Medicare and Medicaid Services (CMS) provided an exception under Medicare’s incident to rules that permits clinical staff to provide the CCM service incident to the services of the billing physician/practitioner under the general supervision (rather than direct supervision) of a physician/practitioner. “General supervision” means the service is furnished under the billing physician/practitioner’s overall direction and control, but that person could be on call and not necessarily on site in the office.

Yes, it depends on the plan. From our experience, most Medicare Advantage plans do pay for CCM.
Yes, on a state-by-state basis.