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 does Lola do within a CCM program?
Lola supports routine patient outreach through scheduled wellness calls, structured responses and call summaries for the care team. Providers can use that information to identify follow-up needs and review concerns. The service supports patient engagement; it does not replace a comprehensive care plan, clinical judgment or the provider’s responsibility to deliver and document qualifying care.
What work remains with clinical staff?
Clinical staff remain responsible for reviewing relevant information, assessing concerns, coordinating care and documenting their work under the provider’s supervision. Automated call duration is not clinical staff time. The billing team must verify qualifying activities and all applicable requirements; an AI summary does not independently make a patient eligible for reimbursement or establish a billable service.
How are concerning patient responses handled?
Positive Check surfaces concerning responses for care-team review through its alert workflow. Before launch, agree the escalation rules, responsible staff, coverage hours and process for failed handoffs. Do not assume that an automated alert guarantees an immediate clinical response. Patient instructions should explain the service’s limits and the appropriate route for urgent or emergency care.
When is staff-led outreach a better fit?
Staff-led outreach can be the better fit when patients need complex conversations, established relationships or support that a structured call cannot provide. It may also be sufficient when the existing team reliably meets patient needs. Compare patient experience and staff workload before changing the process; automation should address a measured operational need, not an assumed staffing shortage.
What should we prepare before launching a CCM pilot?
Choose a defined cohort and workflow, then identify clinical, operations and technical owners. Review patient eligibility and consent, data-transfer requirements, call preferences and escalation coverage before sharing production records. Confirm the implementation scope with Positive Check and test with synthetic data first. Public contact and demo forms should not contain patient health information.
How should we evaluate the first pilot?
Compare the pilot with a documented starting point for the same workflow. Track attempted and completed contacts, staff review time, alert response times and patient opt-outs using agreed definitions and reporting periods. Include software and retained staffing costs. Review unsuccessful calls and handoffs before expanding; enrollment growth alone does not establish clinical benefit or a financial return.
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.
Billing reference: CMS MLN CCM Booklet. Published by Positive Check. Content updated September 13, 2026.