RPM Manual
The practical 2026 guide to device rules, day thresholds, management time, and audit defensibility for Remote Patient Monitoring.
Read the RPM Guide →
Operational Guide
Chronic Care Management (CCM)
A practical Medicare-focused reference for billing CCM by the calendar month--including eligibility, initiating visit and consent, required service elements (electronic care plan, 24/7 access, continuity), time thresholds, and concurrency rules for 99490/99439, 99491/99437, 99487/99489, and G0506.[1]
Use this page as an operational guide--not legal advice. Coverage and edits vary by payer and MAC. Always confirm your specific contracts and local guidance.
Contents
- Key takeaway in one sentence
- What CCM is (and what it is not)
- Eligibility, initiating visit, and consent
- Required service elements and documentation
- Code families and time thresholds
- What counts as CCM time (and what never can)
- Concurrent billing and stacking rules
- Month-end workflow (operational checklist)
- Rates and patient cost-sharing
- What’s changing in 2026 (high level)
- Frequently asked questions
- References
- How FairPath automates CCM at scale
Key takeaway
CCM is billable only when the record supports: (1) eligibility (2+ chronic conditions), (2) an initiating visit and documented consent,
(3) required service elements including an electronic comprehensive care plan and 24/7 access/continuity, and (4) the correct CCM code family
with time that is not double-counted with any other billed service.[1]
What CCM Is (and What It Is Not)
CCM (Chronic Care Management) is a calendar-month care-management service for patients with multiple chronic conditions. It pays for non-face-to-face work such as care coordination, patient/caregiver communication, medication management, and ongoing maintenance of an electronic care plan.[1]
CCM can be furnished by clinical staff under general supervision (the 99490/99439 and 99487/99489 families) or personally by the billing practitioner (99491/99437). You choose the correct “lane” per patient-month; you do not mix lanes for the same patient in the same calendar month.[1]
CCM is not a general bucket for minutes. Minutes must reflect CCM-eligible activities and cannot be used to support another billed code. The most common denial and audit failures come from missing prerequisites (consent, initiating visit, care plan elements) or from double-counting time across concurrent services.[1]
Eligibility, Initiating Visit, and Consent
Eligibility
The patient must have two or more chronic conditions expected to last at least 12 months (or until death). New for 2026: CMS explicitly includes Infection-Associated Chronic Conditions (IACCI) like Lyme disease and Long COVID (ME/CFS) as qualifying conditions. These must place the patient at significant risk of death, acute exacerbation, or functional decline.[5]
Initiating Visit
For new patients or those not seen within the previous year, an initiating visit is required (E/M, AWV, or IPPE). CMS also describes HCPCS G0506 as a one-time add-on for comprehensive assessment and care planning performed by the billing practitioner when applicable.[1]
Consent
Patient consent (written or verbal) must be obtained and documented before billing. CMS expects patients be informed about cost-sharing, that only one practitioner bills CCM per month, and that they can stop CCM at any time (effective end of month).[1]
Practical documentation standard
For audit-ready billing, your record should clearly show: (a) eligibility, (b) initiating visit date/type (when required),
(c) consent content and date, and (d) where the comprehensive care plan lives and how it is maintained over time.[1]
Required Service Elements and Documentation
CMS outlines core CCM service elements. Treat these as a month-level checklist: you are not only accumulating minutes--you are furnishing a defined service bundle that must be supported in the record.[1]
Electronic recording and accessibility
Patient information and the CCM care plan should be recorded using certified EHR technology and be accessible to those furnishing CCM, as appropriate.[1]
Comprehensive electronic care plan
A patient-centered, comprehensive care plan for all health issues should be established, implemented, revised, and monitored. The care plan should support coordination across settings and providers as appropriate, and patients/caregivers should be able to receive a copy as needed.[1]
24/7 access and continuity
Patients must have access to clinicians/clinical staff for urgent needs and continuity with a designated care team member. This is operational, not abstract: you should be able to explain (and show) how after-hours access works and who owns ongoing continuity for the patient.[1]
Care coordination and transitions
CCM includes coordination with home/community services, managing transitions (including follow-up after ED/hospital discharge), and other care coordination activities that reduce fragmentation and improve longitudinal outcomes.[1]
Complex CCM adds MDM
For complex CCM (99487/99489), there must be moderate-to-high complexity medical decision making by the billing practitioner in addition to the time threshold.[1]
Code Families and Time Thresholds
CCM codes are structured as three mutually exclusive “lanes” per patient per calendar month. Choose the correct lane based on who furnished the time and whether complex CCM criteria are met.[1]
Critical Update for RHCs & FQHCs (2026)
HCPCS Code G0511 sunsetted on Sept 30, 2025. As of Oct 1, 2025, Rural Health Clinics and FQHCs must report individual CPT codes (e.g., 99490) instead of the bundled G-code. Additionally, psychiatric collaborative care code G0512 is no longer payable after Dec 31, 2025.[5]
Lane 1
Clinical Staff CCM (Non-complex)
General supervision; time may be furnished by clinical staff under direction of the billing practitioner.
99490 1st 20 mins
99439 ea. add'l 20 mins
You may report add-on time only when the full additional threshold is met for that month.[1]
Lane 2
Practitioner Time CCM
Time personally performed by the billing practitioner (physician/QHP); clinical staff time does not count for these codes.
99491 1st 30 mins
99437 ea. add'l 30 mins
Do not report practitioner-time CCM in the same month as clinical-staff CCM or complex CCM for the same patient.[1]
Lane 3
Complex CCM
Clinical staff time plus moderate-to-high complexity medical decision making by the billing practitioner.
99487 1st 60 mins
99489 ea. add'l 30 mins
Do not report complex CCM in the same month as non-complex CCM or practitioner-time CCM for the same patient.[1]
Common coding error
Mixing lanes within the same calendar month (for example, reporting 99490 and 99491 for the same patient-month) is not compliant.
Decide the lane up front and keep time accounting clean for that month.[1]
What Counts as CCM Time (and What Never Can)
Countable Activities
CCM time is cumulative within the calendar month and must reflect eligible care management activities.
- Patient or caregiver communications related to chronic condition management and care plan goals.[1]
- Medication management and coordination (reconciliation, adherence barriers, refill coordination, side-effect follow-up).[1]
- Coordination with other providers and services (referrals, follow-up on consult results, arranging community resources).[1]
- Care plan creation, monitoring, revision, and documentation supporting longitudinal management.[1]
- Transition-related coordination as part of CCM (when not counted toward another billed service).[1]
Hard lines to avoid
If time supports another billed code, it cannot also support CCM.[1]
- No double-counting: the same minutes cannot be used for CCM and another time-based or bundled service in the same patient period.[1]
- No “estimated minutes”: use contemporaneous time logs tied to specific tasks; audits fail when time is reconstructed or generalized after the fact.[1]
- No lane-mixing: practitioner-time CCM (99491/99437) requires personally performed time; clinical staff time does not count toward those codes.[1]
Concurrent Billing "Stacking" Matrix
Can you bill CCM in the same month as other services? Use this reference table to prevent double-billing denials.
| Service | Allowed with CCM? | Critical Constraint |
|---|---|---|
| RPM (Remote Monitoring) | YES | Must meet requirements independently. Never double-count time. (e.g., The minute spent reviewing BP data counts for RPM, not CCM). |
| TCM (Transitional Care) | YES | Allowed if service periods do not overlap. Best practice: Finish TCM 30-day period, then restart CCM. Do not count TCM face-to-face time toward CCM. |
| BHI (Behavioral Health) | YES | Rare but allowed if distinct. Requires separate consent and clear distinction of effort (medical vs. behavioral). |
| PCM (Principal Care) | NO | Generally not billed by the same practitioner. CCM covers "all conditions," making PCM duplicative for the same provider. |
| Home Health (G0181) | NO | You cannot bill CCM during the same service period as Care Plan Oversight codes (G0181/G0182). |
Month-End Workflow (Checklist)
Treat CCM as a patient-month evidence packet. If you can’t print (or export) the evidence cleanly, you’re not ready to bill. This checklist is the minimum operational standard.[1]
- The "Narrative of Need": It is not enough to list conditions. The record must include a brief note explaining why management was necessary this month (e.g., "Review of unstable blood sugar logs; adjusted insulin").[8]
- The "Living" Care Plan: A static PDF from last year does not count. The system must show that the care plan was accessed, monitored, or revised during the service period.[1]
- Time Log Specificity: "Estimated" time is an automatic audit failure. Logs must show specific dates, duration (e.g., "11:04 AM - 12 mins"), and the specific task performed.[1]
- "Stop Date" Verification: Verify no "zombie billing." If a patient revoked consent or died during the month, ensure billing is stopped immediately. (Note: You cannot bill CCM if the patient was an inpatient for the entire month).[2]
- Lane & Concurrency Check: Confirm you are not billing RPM and CCM for the same minutes, and that you haven't mixed "Clinical Staff" (99490) and "Doctor Time" (99491) codes.[1]
"What If?" Audit Defense Scenarios
The "Mid-Month Hospital" Case
Scenario: Patient is admitted to the hospital on the 15th and stays through the 25th. Can we bill CCM for this month?
Verdict: YES (Conditional).
You may bill CCM if you provided >20 minutes of care during the outpatient portion of the month (Days 1-14 or 26-30). You cannot count any time spent managing the patient while they are inpatient. If the patient is inpatient for the entire month, you cannot bill CCM.
You may bill CCM if you provided >20 minutes of care during the outpatient portion of the month (Days 1-14 or 26-30). You cannot count any time spent managing the patient while they are inpatient. If the patient is inpatient for the entire month, you cannot bill CCM.
The "Duplicate Provider" Case
Scenario: A cardiologist bills PCM (Principal Care Management) and the PCP bills CCM for the same patient in the same month.
Verdict: DANGER.
Generally, Medicare will only pay one care management claim per beneficiary per month. The first claim processed is paid; the second is denied. Providers must coordinate to avoid "racing" for the claim. PCM and CCM generally should not be billed by the same practitioner.
Generally, Medicare will only pay one care management claim per beneficiary per month. The first claim processed is paid; the second is denied. Providers must coordinate to avoid "racing" for the claim. PCM and CCM generally should not be billed by the same practitioner.
The "Sudden Stop" Case
Scenario: Patient revokes consent on the 20th. You have already logged 15 minutes.
Verdict: DO NOT BILL.
If the patient revokes consent, services cease effectively. If you have not met the 20-minute threshold before the revocation, you cannot bill. If you met the threshold on the 10th and they revoke on the 20th, the bill is valid, but no further billing should occur for subsequent months.
If the patient revokes consent, services cease effectively. If you have not met the 20-minute threshold before the revocation, you cannot bill. If you met the threshold on the 10th and they revoke on the 20th, the bill is valid, but no further billing should occur for subsequent months.
Retention Toolkit: Stopping the "Churn"
The "Welcome Letter" Defense
Patients often quit after the first bill because of "sticker shock" over the ~$8 coinsurance. The fix: Pre-empt the shock. Send a Welcome Letter before the first claim goes out.
Template Snippet:
"As we discussed, Medicare covers 80% of this service. You may see a small coinsurance amount (typically $8-$12) on your statement, similar to a copay for an office visit. This allows us to keep checking on your health every month without you needing to drive in."
The "Motivational" Check-In
If staff just ask "How are you?", patients feel nagged. If they ask "What are your goals?", patients feel cared for. Use Motivational Interviewing techniques to make the 20 minutes fly by.
- "Did you take your meds?" (Nagging)
- "What challenges are you facing with your meds this week?" (Partnership)
- "Call us if you need anything." (Passive)
- "I'll call you next Tuesday to see how that new prescription is working." (Proactive)
Compliance Warning
Vendor Arrangements & Legal Guardrails
Many practices outsource CCM to vendors. If you do, you retain full liability. Be aware of the specific "Safe Harbor" and "Incident-To" risks that 2026 audits target.
The "Percentage Fee" Trap
Risk: Anti-Kickback Statute (AKS)
Paying a vendor a percentage of your Medicare collections (e.g., "we take 50% of revenue") is a significant risk. The OIG may view this as remuneration to induce referrals, which can implicate the AKS.[7]
Safe Harbor: Flat-fee arrangements based on Fair Market Value (FMV) are the defensible standard for personal services arrangements.
The "Black Box" Trap
Risk: Incident-To Violations
You cannot simply "sign up" patients and let a vendor run the program. CMS requires clinical integration. If you do not actively direct the care or handle escalated issues, you are not furnishing the service, and the claim may be false.[1]
Requirement: You must own the data. If an auditor asks for a time log, you must be able to produce it immediately--not ask a vendor for permission.
Rates and Patient Cost-Sharing
CCM payments vary by locality and setting. For official amounts, use the CMS Physician Fee Schedule Look-Up Tool and confirm payer contracts. CCM typically carries Part B cost-sharing (coinsurance/deductible), which must be disclosed during consent.[1][3][4]
Implementation tip: treat “consent” as both a compliance requirement and a patient-experience requirement--unexpected monthly coinsurance is a common cause of patient confusion.
What’s Changing in 2026?
CCM code mechanics and core requirements are stable, but CMS finalized broader 2026 policy updates that affect how practices structure care management (including APCM refinements and related program alignment). Treat 2026 as a year to tighten month-level evidence, concurrency guardrails, and documentation coherence across care-management programs.[5]
Frequently Asked Questions
1
Can we bill RPM and CCM in the same month?
Yes, if requirements are met independently. New for 2026: The strict "16-day" rule for RPM has been relaxed with new codes (99445 for 2-15 days), making it easier to stack these programs. However, you must never double-count the same minute of time for both services.[5]
2
Can we bill APCM and CCM together?
3
What exactly counts toward the CCM time threshold?
CCM time includes qualifying care coordination and care management activities (patient/caregiver communications, medication management, care-plan monitoring/revision, referrals and follow-up, and coordination across settings). The same minutes cannot be used for CCM and another billed service.[1]
4
Who can furnish CCM and under what supervision?
Clinical staff may furnish CCM incident-to under general supervision of the billing practitioner (who provides overall direction and remains responsible for the patient’s care). Practitioner-time codes (99491/99437) require time personally performed by the billing practitioner.[1]
5
Do we need an initiating visit and consent?
Yes. For new patients or patients not seen within the previous year, CMS requires an initiating visit (E/M, AWV, or IPPE) and documented consent before billing CCM. Consent must include cost-sharing disclosure and the one-practitioner-per-month rule, and patients can revoke consent at any time (effective end of month).[1]
6
Can we report complex CCM and regular CCM in the same month?
No. Do not report complex CCM (99487/99489) in the same calendar month as non-complex CCM (99490/99439) or practitioner-time CCM (99491/99437) for the same patient.[1]
How FairPath Automates CCM at Scale
CCM is manageable when you treat it as a patient-month evidence system: prerequisites, care-plan elements, time accounting, and concurrency guardrails. FairPath automates the evidence plumbing so teams can focus on care delivery while keeping claims defensible.
Time capture with audit trail
CCM-eligible work is logged as structured events so month totals can be validated and exported.
Lane enforcement
Prevents mixing practitioner-time CCM with clinical-staff CCM for the same patient-month.
Concurrency guardrails
Flags prohibited overlaps and enforces “no double counting” constraints across CCM and other services.
Month-end readiness
Surfaces patients who meet prerequisites and thresholds and supports consistent claim generation workflows.
References
-
CMS MLN Booklet: Chronic Care Management Services (ICN MLN909188, June 2025).
Includes eligibility, initiating visit & consent, electronic care plan/EHR, 24/7 access, supervision, and code times.
PDF - CMS MLN Booklet: Chronic Care Management Services (ICN MLN909188, June 2025) – concurrency and stacking. Clarifies interaction with RPM/RTM, TCM, complex vs non-complex CCM, ESRD, home health, hospice, and other care-management codes. Same document as [1], focused on the concurrency sections.
-
CMS: Advanced Primary Care Management (APCM) Services overview (May 12, 2025).
Monthly bundle; auxiliary personnel under general supervision; integrates CCM-like elements and supports hybrid primary care payment models.
Web -
CMS: PFS Look-Up Tool Overview (official rate lookup).
Web -
CMS: Search the Physician Fee Schedule (interactive search).
Web -
CMS Fact Sheet: CY 2026 Medicare Physician Fee Schedule Final Rule (Oct 31, 2025).
Describes APCM refinements, APCM behavioral-health add-on codes (G0568–G0570), and related updates to care-management and remote-monitoring policy.
Web - OIG/HHS: General Compliance Guidance for Third-Party Medical Billing Companies (implications for percentage-based fees).
- Noridian/Novitas MAC Guidance: Documentation Requirements for CCM (Narrative of Need and Time Logging specificity).
- OIG Report: Medicare Continues to Make Overpayments for CCM (Audit focus on duplicate billing and inpatient status overlaps).
-
HHS Telehealth Guidance: Remote Patient Monitoring and Remote Therapeutic Monitoring (2024–2025).
Clarifies that RPM and RTM can’t both be billed for the same patient and time period, and how they interact with CCM and other care-management services.
Web
