CCM Solution
Chronic Care Management at Scale
Daily AI wellness calls give your CCM patients consistent touchpoints, medication adherence checks, and care plan follow-up — all documented and ready for billing.
$66
Non-Complex CCM / Mo
$144
Complex CCM / Mo
99490
First 20 Min — $66
99487
Complex 60 Min — $144
What Is Chronic Care Management?
Chronic Care Management (CCM) is a Medicare program that reimburses providers for non-face-to-face care coordination services for patients with two or more chronic conditions. Services include care plan development, medication management, and ongoing patient communication.
CMS requires at least 20 minutes of clinical staff time per patient per month for standard CCM (99490), with additional codes for more complex patients (99487) and additional time blocks (99439). The challenge is documenting this time and maintaining consistent patient contact across large populations.
How Positive Check Supports CCM
Structured daily calls provide the consistent patient touchpoints your CCM program needs.
Medication Adherence
Daily calls include medication check-ins, asking patients about doses taken, side effects, and refill needs — key documentation for CCM.
Care Plan Follow-Up
Structured wellness questions align to each patient's care plan, generating documented follow-up touchpoints for CCM billing.
Alert-Triggered Callbacks
When a call flags a concern, care teams receive immediate alerts — generating additional documented care coordination time for CPT 99439.
Complex Patient Support
For patients with multiple chronic conditions, daily monitoring with escalation protocols supports the higher documentation bar for CPT 99487 and 99489.
CCM Billing Codes
2026 Medicare national average reimbursement rates for Chronic Care Management.
| CPT Code | Description | 2026 Rate |
|---|---|---|
| 99490 | CCM — first 20 min non-complex chronic care management | $66 |
| 99439 | CCM — each additional 20 min non-complex CCM (up to 2x/month) | $48 |
| 99487 | Complex CCM — first 60 min for patients with multiple chronic conditions | $144 |
| 99489 | Complex CCM — each additional 30 min beyond the 99487 threshold | $72 |
Why Providers Choose Positive Check for CCM
Consistent daily patient touchpoints without manual outreach
Medication adherence tracking built into every call
Documented care coordination time supports 99490 and 99439 billing
Escalation protocols for complex patients meet 99487 requirements
Real-time alerts when patients report changes or concerns
Works alongside your existing care management workflows
Combine with RPM for $159-$237/patient/month in revenue
HIPAA-compliant with full audit trail
Frequently Asked Questions
What is Chronic Care Management (CCM)?
Chronic Care Management is a Medicare-reimbursed care coordination program for patients with two or more chronic conditions expected to last at least 12 months (or until death) and that place the patient at significant risk of death, acute exacerbation, or functional decline. Clinical staff deliver non-face-to-face care coordination — medication management, care plan updates, patient communication — and bill CPT 99490 (first 20 minutes non-complex), 99439 (each additional 20 minutes), 99487 (first 60 minutes complex), and 99489 (each additional 30 minutes complex).
What is the two-chronic-conditions requirement?
To qualify for CCM, a patient must have two or more chronic conditions. This distinguishes CCM from RPM (which requires only one chronic condition) and from Principal Care Management (PCM, which is specifically for a single high-risk condition). The chronic conditions must be documented in the patient’s medical record and must be expected to last at least 12 months or until death. Common qualifying combinations include hypertension + diabetes, COPD + heart failure, and diabetes + chronic kidney disease.
What is the 20-minute monthly clinical staff time requirement?
CPT 99490 requires at least 20 minutes of clinical staff time per calendar month spent on CCM activities for a given patient. The time can be cumulative across multiple touchpoints in the month — a 5-minute medication check call, a 10-minute care plan update, and a 5-minute specialist-coordination task all count toward the threshold. If the cumulative time reaches the 20-minute mark, 99490 is billable. If it does not, no CCM code can be billed for that patient that month. Each additional 20 minutes may be billed under 99439 (up to twice per month for non-complex CCM).
Can AI-powered wellness calls count toward the 20-minute CCM time requirement?
AI calls themselves do not count as "clinical staff time" under the CMS definition, but clinical staff time spent reviewing AI call summaries, updating care plans based on flagged concerns, coordinating escalations, and documenting the interaction does count. In practice, AI calls generate structured summaries that make the 20-minute clinical review highly efficient — the call captures the patient content, clinical staff spend their time on care-plan action rather than data gathering.
What's the difference between non-complex (99490) and complex (99487) CCM?
Non-complex CCM (CPT 99490, ~$66/month) requires 20 minutes of clinical staff time and at least one moderate-complexity medical decision-making element per month. Complex CCM (CPT 99487, ~$144/month) requires 60 minutes of clinical staff time and substantial revision of the care plan for patients with moderate-to-high complexity medical decision-making. Complex CCM applies to patients with unstable conditions, recent hospitalizations, or significant care-plan changes. A patient can only be billed under one track per month — either non-complex or complex, not both.
Does HIPAA permit AI-powered CCM wellness calls?
Yes, when the vendor operates under a signed Business Associate Agreement (BAA) and the platform implements HIPAA technical safeguards — encryption in transit and at rest, role-based access, audit logging, and minimum-necessary data handling. Positive Check operates under a BAA for all provider engagements.
Further Reading
Billing guide
CPT 99490 Billing Guide
Eligibility, the 20-minute requirement, documentation, and how 99439/99487/99489 stack.
Eligibility
The 2-Chronic-Conditions Requirement
Which combinations qualify, documentation expectations, and the line between CCM and PCM.
Workflow
The 20-Minute Monthly Requirement
How time is tracked, what counts as clinical staff time, and common documentation pitfalls.
Comparison
AI Calls vs. In-House Care Coordinators
Category-level comparison of automated engagement versus staffing an in-house CCM team.
Reviewed against current CMS billing guidance. CMS MLN CCM Booklet. Last updated 2026-04-20.