Chronic Care Management

Chronic Care Management

CCM at a glance

117 million Americans have one or more chronic health conditions. That’s half of the adult population of the U.S.

Medicare began allowing physicians to bill for chronic care management (CCM) in 2015.

CMS specifies that the code must be billed for “non-face-time follow-up care outside the office” each month.

Whitepaper: New Options in Chronic Care Management

This whitepaper discusses why the CCM program was created, which patients qualify for the program and its benefits to patients and physicians’ practices.

Download the Whitepaper

whitepaper cover - New options in chronic care management

The facts


Chronic diseases and conditions — like heart disease, stroke, cancer, diabetes, obesity, and arthritis — are among the most common and costly health problems.


2/3 of Medicare beneficiaries have 2 or more chronic conditions.


Patients with multiple chronic conditions often visit multiple providers in different organizations, leading to duplication and conflicts in Care Plans.

What CCM does for practices

  • It reimburses physician practices for providing ongoing care to Medicare patients with chronic conditions.
  • It helps providers proactively manage patient health rather than only treating disease and illness.
  • It brings a systematic approach to defining and managing a patient’s Care Plan.
  • It organizes care coordination under one provider.

What CCM does for patients

  • It provides patients with a care coordinator that closely monitors their health.
  • It helps patients better understand their Care Plan.
  • It develops meaningful relationships between providers and patients.
  • It offers added care for free for most patients.

CCM for Patients

Understanding the Requirements of Code 99490

This code is specific to Chronic Care Management and is the reimbursement of chronic care services for patients with 2 or more chronic conditions.
To be reimbursed for such care, practices must:


Conduct at least 20 minutes of non face-to-face care


Contact each eligible patient every month


Establish, implement, revise or monitor a comprehensive care plan

What’s involved in CCM


Structured Data Recording

In a Meaningful Use I or II certified EHR


Care Plan

Patient-centered, accessible and sharable electronically where appropriate


24/7 Access to Care

Continuity of care with designated care team member and enhanced communication opportunities


Manage Care

Systematic and documented patient contact, medication reconciliation and care coordination

The Challenge of CCM

"Many providers struggle to balance the 24/7 needs of chronically ill patients within the huge scope of their duties, unable to devote staff to the full-time job of communicating with and creating care plans for these patients outside of face-to-face office visits."
— Michelle Li, MD
Internal Medicine

That’s why we’re here. We make CCM effective for your patients and simple for your practice.

You can do it yourself, or do it effortlessly with Wellbox.