What is CCM (Chronic Care Management)?

Definition

Chronic Care Management (CCM) is the Medicare reimbursement framework for non-face-to-face care coordination provided to patients with two or more chronic conditions expected to last at least 12 months. CMS established CCM in CY2015 as one of the first dedicated care-management payment mechanisms in the Physician Fee Schedule. Its activities are now substantially consolidated into APCM beginning CY2025, though CCM codes remain billable.

The CCM code family

CCM is billed under a set of CPT codes that distinguish staff-time-based and provider-time-based services, with add-on codes for additional time:

• 99490 — Non-complex CCM, first 20 minutes of clinical staff time per calendar month, directed by a physician or qualified health professional.
• 99439 — Add-on for each additional 20 minutes of clinical staff time beyond 99490, up to a defined monthly maximum.
• 99487 — Complex CCM, first 60 minutes of clinical staff time per calendar month, requiring moderate or high-complexity medical decision-making.
• 99489 — Add-on for each additional 30 minutes of complex CCM clinical staff time.
• 99491 — CCM services personally performed by the physician or qualified health professional, first 30 minutes per calendar month.

Each code carries specific time thresholds that must be met and documented within the calendar month for the code to be billable.

What CCM covers

CMS designed CCM to reimburse the coordination work that occurs outside of office visits — the work primary-care practices had historically performed without dedicated payment. Covered activities include:

• Comprehensive care plan creation, maintenance, and sharing with the patient.
• Medication reconciliation and management.
• Coordination with other treating clinicians, including specialists and home-health providers.
• 24/7 access to a care team member for urgent care-management needs.
• Transitions-of-care management between settings (hospital, skilled nursing, home).
• Patient and caregiver communication outside of office visits, including secure messaging and telephone outreach.

A patient must consent to CCM services, and the practice must maintain a certified electronic health record meeting CMS’s specifications.

Relationship to APCM

The CY2025 Physician Fee Schedule Final Rule introduced APCM (codes G0556, G0557, G0558) as a successor framework that consolidates the activities CCM was designed to reimburse — along with elements of Principal Care Management and Transitional Care Management — into a tiered per-member-per-month payment. CMS articulated two motivations: reducing the time-tracking burden that constrained CCM adoption, and unifying multiple overlapping care-management code families.

CCM and APCM cannot be billed concurrently for the same patient in the same calendar month. Practices choose one framework per patient per month based on which better fits the patient’s complexity and the practice’s documentation workflow. CCM remains billable in CY2025 and CY2026; APCM is positioned by CMS as the increasingly preferred framework as practices migrate.

Practical positioning

For practices considering the transition, the central differences are:

• Time-tracking: CCM requires documentation of specific time thresholds per month per patient. APCM does not require equivalent monthly time-threshold documentation.
• Tier structure: CCM distinguishes complex versus non-complex; APCM uses three tiers including a dual-eligible tier (G0558).
• Add-on stackability: CCM uses add-on codes for additional time. APCM is a single PMPM code per patient per month.
• Behavioral health integration: APCM has dedicated BH add-on codes (G0568-G0570) finalized in CY2026; CCM does not have a parallel BH-specific add-on within the same framework.

For a detailed comparison, see APCM vs CCM: What changes, what stays the same.

Primary sources

• Centers for Medicare & Medicaid Services. CY2015 Medicare Physician Fee Schedule Final Rule — original CCM payment policy.
• CMS Chronic Care Management Services factsheets (ICN 909188 / MLN booklets, current revisions).
• Centers for Medicare & Medicaid Services. CY2025 Medicare Physician Fee Schedule Final Rule — APCM establishment.
• CPT code descriptors for 99490, 99439, 99487, 99489, 99491.

Related concepts

For the successor framework, see What is APCM?. For the side-by-side comparison, see APCM vs CCM. For the broader payment model, see What is PMPM?.