Structured monthly care coordination for Medicare patients with two or more chronic conditions. The foundation of care management that delivers predictable revenue and better patient outcomes.
Chronic Care Management (CCM) is a Medicare program that reimburses healthcare providers for non-face-to-face care coordination services for patients with multiple chronic conditions. Introduced by CMS in 2015, CCM recognizes that managing chronic diseases requires ongoing attention between office visits.
For independent practices, CCM represents a significant revenue opportunity while improving patient outcomes. When delivered effectively, CCM reduces hospitalizations, improves medication adherence, and helps patients better manage their conditions between visits.
Revenue opportunity: A practice with 500 Medicare patients can typically identify 150–200 CCM-eligible patients, generating $50,000–$100,000+ in additional annual revenue when the program is fully implemented.
To qualify for CCM services, patients must meet the following criteria:
A comprehensive CCM program includes the following elements, all of which CareStream manages on behalf of your practice:
CCM services are billed using the following CPT codes based on time spent and complexity:
| CPT Code | Description |
|---|---|
| CPT 99490 | First 20 minutes of clinical staff time per calendar month |
| CPT 99439 | Each additional 20 minutes of clinical staff time |
| CPT 99491 | First 30 minutes of physician/QHP time per calendar month |
| CPT 99437 | Each additional 30 minutes of physician/QHP time |
CareStream operates CCM as a fully managed service. Our team handles the operational complexity while your practice maintains clinical oversight:
Automated analysis of your EHR data to identify eligible patients.
Compliant consent collection through phone, SMS, or in-practice workflows.
Comprehensive care plans aligned with patient goals and conditions.
AI-assisted patient outreach and monitoring with regular check-ins.
Automated documentation of all billable activities, with no manual logs.
Intelligent routing of clinical issues to your care team when needed.
Compliant claim generation with audit-ready documentation.
While CCM has been the standard for care management billing, APCM offers a simplified alternative for many practices. Consider CCM if:
Consider APCM if you want simplified billing without time tracking requirements. Many practices are transitioning to APCM for its reduced administrative burden. Learn more about APCM →
We handle the complexity so your practice can generate predictable monthly Medicare revenue.
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