Chronic Care Management for Medicare Patients
Provide ongoing, non-face-to-face support for Medicare patients with multiple chronic conditions — improving outcomes, strengthening engagement, and generating sustainable revenue without adding staff burden.
CHRONIC CARE MANAGEMENT
Why Chronic Care Matters
Every day, your team supports patients managing multiple chronic conditions — coordinating care, answering questions, and helping patients stay on track between visits. Medicare’s Chronic Care Management (CCM) program recognizes this ongoing work and allows practices to be reimbursed for providing structured, non-face-to-face care.
When implemented effectively, CCM improves patient engagement, supports medication adherence, and helps reduce avoidable utilization — while creating a predictable, recurring revenue stream for your practice.
What Chronic Care Management Delivers
Patients living with multiple chronic conditions need consistent support beyond the exam room. Chronic Care Management (CCM) enables practices to deliver structured, non-face-to-face care coordination that improves outcomes, strengthens engagement, and supports long-term health — while generating predictable Medicare revenue.
Between-Visit Patient Support
CCM provides ongoing care coordination between office visits — helping patients manage chronic conditions, stay engaged in their care, and avoid unnecessary complications through regular outreach and follow-up.
Medicare Compliant CCM
With CCM, practices can deliver structured, compliant care coordination that meets Medicare requirements — including documented care plans, patient consent, and monthly non-face-to-face services.
Predictable Monthly Revenue
Medicare reimburses CCM for as little as 20 minutes of qualifying care coordination per patient each month — turning routine patient support into sustainable, recurring revenue without adding staff burden.
More than Technology. More than staffing.
Most EHRs bolt on CCM modules. At Managing Care Solutions, we combine Smartlink Health’s purpose-built CCM platform with a dedicated team — trained professionals supervised by RNs and physicians.
The result: better patient engagement, compliant billing, and sustainable revenue for your practice.
- 20+ Years in Care Management
- 1.5M Patients Supported
- Evidence-based Patient Talk Tracks
- 100% CMS-Compliant Programs
Ready to unlock new revenue while improving patient care? Let’s talk about the right CCM solution for your practice.
The 20-Minute Rule
With just 20 minutes of non-face-to-face care coordination per patient each month, your practice can bill Medicare CPT 99490 — turning routine patient support into sustainable, recurring revenue.
Choose a CCM Solution that Fits Your Practice
Launch CCM with confidence — or strengthen an existing program — using a care management model that aligns with your workflows and goals.
Choose from turnkey CCM services, hybrid support, or targeted training to optimize performance and compliance without disrupting day-to-day operations.
Chronic Care Management Frequently Asked Questions
Chronic care management can feel complex. Below are answers to the most common questions providers and patients ask about CCM — including eligibility, billing, and how the program works.
“Chronic care management services of at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored.” (CMS Final Rule, October 31, 2014)
Transitional Care Management (TCM) is a Medicare-covered service that supports a patient’s safe transition back to the community after an inpatient or observation stay. TCM includes both non-face-to-face care coordination and a required follow-up visit, focused on preventing complications, closing gaps, and reducing avoidable readmissions during the 30-day post-discharge period.
CMS has not defined a specific list of conditions. Some examples of chronic conditions include the following (and there may be many more that qualify):
- Alzheimer’s disease and related dementia
- Arthritis (osteoarthritis and rheumatoid)
- Asthma
- Atrial fibrillation
- Autism spectrum disorders
- Cancer
- Chronic Obstructive
- Pulmonary Disease
- Depression
- Diabetes
- Heart failure
- Hypertension
- Ischemic heart disease
The TCM period begins on the date of discharge and continues for the next 29 days (a total 30-day period).
Physicians and the following non-physician practitioners may bill the new CCM service:
- Certified Nurse Midwives;
- Clinical Nurse Specialists;
- Nurse Practitioners; and
- Physician Assistants.
Note: Only one practitioner may be paid for the CCM service for a given calendar month.
TCM applies when the patient is discharged from specific inpatient or partial-hospitalization settings (including acute care hospitals, SNFs, inpatient rehab, inpatient psych, long-term care hospitals, observation, and partial hospitalization programs) and returns to a community setting (home, assisted living, nursing facility, etc.).
Yes. CMS requires the billing practitioner to furnish an Annual Wellness Visit (AWV), Initial Preventive Physical Examination (IPPE), or comprehensive evaluation and management visit to the patient prior to billing the CCM service, and to initiate the CCM service as part of this exam/visit. Managing Care Solutions can assist your practice in the hiring, training, and QA of medical office assistants to perform these AWVs.
TCM requires all of the following:
-
Interactive contact with the patient/caregiver within 2 business days of discharge (phone, email, or face-to-face).
-
Medication reconciliation and management on or before the follow-up visit.
- One face-to-face visit within the required time-frame:
- 99495: within 14 calendar days + at least moderate medical decision making (MDM)
- 99496: within 7 calendar days + high medical decision making (MDM)
- Establishment of an individual’s medical/family history.
- Establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual.
- Measurement of an individual’s height, weight, BMI (or waist circumference, if appropriate), BP, and other routine measurements as deemed appropriate, based on the beneficiary’s medical/family history.
- Detection of any cognitive impairment that the individual may have as defined in this section.
Review of the individual’s potential (risk factors) for depression, including current or past experiences with depression or other mood disorders, based on the use of an appropriate screening instrument for persons without a current diagnosis of depression, which the health professional may select from various available standardized screening tests designed for this purpose and recognized by national medical professional organizations. - Review of the individual’s functional ability and level of safety based on direct observation, or the use of appropriate screening questions or a screening questionnaire, which the health professional may select from various available screening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations.
- Establishment of a written screening schedule for the individual, such as a checklist for the next 5 to 10 years, as appropriate, based on recommendations of the United States Preventive Services Task Force (USPSTF) and the Advisory Committee on
- Immunization Practices (ACIP), as well as the individual’s health status, screening history, and age-appropriate preventive services covered by Medicare.
- Establishment of a list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway for the individual, including any mental health conditions or any such risk factors or conditions that have been identified through an IPPE, and a list of treatment options and their associated risks and benefits.
- Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management, or community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition.
- Any other element(s) determined appropriate by the Secretary of Health and Human Services through the National Coverage Determination (NCD) process.
Managing Care Solutions can assist your practice in the hiring, training, and QA of medical office assistants to perform these AWVs.
You may still report TCM if you make two or more timely, separate attempts, document those attempts in the medical record, and you still meet all other requirements (including the on-time face-to-face visit).
A practitioner must inform eligible patients of the availability of and obtain consent for the CCM service before furnishing or billing the service. Some of the patient agreement provisions require the use of certified Electronic Health Record (EHR) technology.
Managing Care Solutions can provide your practice with informative patient brochures, required consent forms, and templates for the patient’s care plan.
Patient consent requirements include:
- Inform the patient of the availability of the CCM service and obtain written agreement to have the services provided, including authorization for the electronic communication of medical information with other treating practitioners and providers.
- Explain and offer the CCM service to the patient. In the patient’s medical record, document this discussion and note the patient’s decision to accept or decline the service.
- Explain how to revoke the service.
- Inform the patient that only one practitioner can furnish and be paid for the service during a calendar month.
This agreement process should include a discussion with the patient, and caregiver when applicable, about:
- What the CCM service is;
- How to access the elements of the service;
- How the patient’s information will be shared among practitioners and providers;
- How cost-sharing (co-insurance and deductibles) applies to these services; and
- How to revoke the service.
Informed patient consent need only be obtained once prior to furnishing the CCM service, or if the patient chooses to change the practitioner who will furnish and bill the service.
Yes. Medicare allows TCM (99495/99496) to be provided via telehealth (subject to Medicare telehealth rules).
(1) Electronic Health Record (certified as a 2011 or 2014 certified EHR/EMR) with capacity to form a structured clinical summary:
- Demographics
- Full List of Problems
- Medications and Medication Allergies
(2) Patients must have 24/7 timely access to address urgent chronic care needs.
(3) Provider must offer continuity of care with provider or member of the care team, so that patient is able to get successive routine appointments.
(4) Care Management Services including:
- Systematic assessment of the patient’s medical, functional, psychosocial needs
- System based approaches to ensure timely receipt of all recommended preventative services
- Medication reconciliation with review of adherence and potential interactions
- Oversight of patient self-management of medications
(5) Development of an electronic patient-centered care plan.
- Must be able to share electronically with other providers
- Provide a copy to patient
(6) Management of care transitions
- Referrals to other clinicians
- Follow-up after an emergency department visit
- Follow-up after discharge from hospital, SNF, or other health care facility
- Must be able to electronically share patient care plan, clinical summary, and other relevant documents
(7) Coordination with home and community-based service providers.
(8) Provider must offer enhanced opportunities for patient to communicate with provider through the use of secure messaging, internet, or other asynchronous non face-to-face communication methods.
(9) Patient’s must sign a consent that includes:
- Nature of CCM and how it may be accessed
- They can stop services at any time
- Only one provider can provide CCM at one time
- Patient’s information will be shared with other providers across the care continuum
- The patient will be responsible for the co-insurance payment
TCM may be provided by physicians (any specialty) and qualified non-physician practitioners (NPs, PAs, CNSs, CNMs) as allowed by state law. Clinical staff and auxiliary personnel may perform certain non-face-to-face components under appropriate supervision rules.
Managing Care Solutions will:
- Assist practices with work flow development; provide brochure and consent forms, as well as templates for the patient’s care plan.
- Provide monthly non-face-to-face care management services telephonically by a CCM Coordinator. CCM Coordinators are certified Medical Office Assistants. They are given specialized training and are supervised by MCS’ Registered Nurses.
- The CCM Coordinator will function as part of the practice team, working closely with each medical practice to deliver the CCM scope of service requirements for billing.
- The CCM Coordinator will document his or her work in Smartlink Health’s Chronic Care Management solution.
- MCS will have read-only access to practice EHR;
- Managing Care Solutions can also assist your practice in the hiring, training, and QA of medical office assistants to perform Annual Wellness Visits.
No. Only one physician or NPP may report TCM services, and you report TCM once per patient during the TCM period.
Smartlink Health is our technology partner. Smartlink is a cloud-based platform that provides technology for:
- Electronically transmitting referrals, care plans, and other documents
- Documenting CCM activities. A built-in timer records the minutes for care coordination activities
- Auditable CCM time tracking records for practice
- Real time management of minutes and follow-up tasks needed per patient
- Asynchronous patient communication via text messaging (can use for transmission of care plans)
Learn more at www.smartlinkhealth.com.
Yes—Medicare notes you may report reasonable and necessary E/M services separately, except you don’t bill the required TCM face-to-face visit separately (it’s included in TCM).
Call us – (980) 264-7006. We’re happy to help!
In some cases, yes. Medicare states you can bill certain other care management services concurrently with TCM when medically reasonable and necessary, and when time/effort isn’t counted more than once.
After the 30-day TCM period ends, many practices continue supporting high-risk patients with Chronic Care Management (CCM) for ongoing between-visit coordination and engagement.
At a minimum, Medicare recommends documenting the patient’s:
- Discharge date
- First interactive contact date
- Face-to-face visit date
- Medical decision making level (moderate or high)
Yes—Medicare notes you can’t bill TCM services when any of the 30-day TCM period falls within a post-operative global surgery period for a procedure billed by the same practitioner.
TCM is short-term, post-discharge support during a defined 30-day transition window. CCM is ongoing support for patients living with multiple chronic conditions—helping them stay on track between visits month after month. Many high-risk patients benefit from TCM first, followed by CCM for continued care coordination.
