Chronic Care Management: How CMS Helps Patients Manage Chronic Conditions

Chronic Care Management (CCM) is an important Medicare program designed to help patients who are living with multiple chronic health conditions. Rather than treating each medical problem separately, CCM takes a more coordinated approach to managing a patient’s overall health.

According to the Centers for Medicare & Medicaid Services (CMS), Medicare covers CCM for eligible patients who have two or more chronic conditions that are expected to last at least 12 months, or until the patient’s death. These conditions must also place the patient at significant risk of death, an acute worsening of their condition, or a decline in their ability to function.

Chronic conditions can include diabetes, hypertension, heart disease, chronic obstructive pulmonary disease (COPD), arthritis, depression, cancer, and many other long-term illnesses.

What Does Chronic Care Management Provide?

The goal of CCM is to make sure patients receive appropriate care between regular office visits. A healthcare professional can help patients understand their treatment plans, coordinate appointments, communicate with specialists, monitor medications, and address problems before they become serious.

CMS describes CCM as including services such as personalized assistance from a healthcare professional, coordination among doctors and other healthcare providers, pharmacies, testing centers and hospitals, and access to healthcare support when needed.

A major component of CCM is the development of a comprehensive care plan. The plan can identify the patient's medical problems, treatment goals, medications, expected outcomes, and necessary follow-up. It can also address cognitive and functional needs, symptoms, caregivers, and coordination with outside healthcare resources.

How Is CCM Paid For?

CMS allows eligible healthcare providers to bill Medicare for CCM services under specific billing codes. For example, CPT code 99490 covers the first 20 minutes of clinical staff CCM services during a calendar month, while 99439 can be used for each additional 20 minutes. More complex patients may qualify for complex CCM services, including codes 99487 and 99489.

CCM therefore creates a financial mechanism for medical practices to provide ongoing care coordination rather than relying solely on traditional office visits.

Why Is CCM Important?

For patients with multiple chronic illnesses, healthcare can become complicated. They may see several doctors, take numerous medications, undergo regular testing, and require frequent communication among providers. Without coordination, important information can be missed.

CCM is designed to bring these pieces together. By maintaining an ongoing relationship with the patient and coordinating care between healthcare providers, CCM can help patients better understand and manage their conditions.

CMS has also expanded its approach to care management. Beginning in 2025, CMS introduced Advanced Primary Care Management services, which combine elements of CCM, Transitional Care Management, Principal Care Management, and certain technology-based services into a broader primary-care model.

In short, CMS views chronic care management as an important part of modern primary care. The objective is simple: help patients manage chronic conditions continuously, coordinate their healthcare more effectively, and receive the support they need between doctor visits.