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Innovations: Chronic Care Management (CCM)

CCM is care coordination services done outside of the regular office visit for patients with multiple (two or more) chronic conditions expected to last at least 12 months. Health care professionals have an opportunity to be separately paid for important services while improving Medicare patients' self-management, health outcomes, and patient satisfaction.

Beneficiary Eligibility

  • Patients must have two or more chronic conditions (expected to last at least 12 months) with significant risk of death, functional decline, exacerbation or decompensation – E.g., hypertension, heart disease, diabetes, high cholesterol, etc.

Provider Eligibility

  • Physician, nurse practitioner, physician assistant, certified nurse midwives & clinical nurse specialists, clinical staff (pharmacists, medical assistants, technicians, nurses, therapists) – Not within scope of license for podiatrists, clinical psychologists or dentists
  • Billing provider only requires to furnish an Annual Wellness Visit (AWV), Initial Preventive Physical Exam (IPPE) or comprehensive Evaluation and Management (E/M) prior to billing CCM for new patients or patients not seen within last 12 months – Established patients may be contacted verbally or through email
  • Must provide "timely access" to electronic patient records
  • CCM services may be provided by clinical staff under direction of billing practitioner on an "incident to" basis (as an integral part of services provided by billing practitioner), subject to applicable State law, licensure and scope of practice
    • Clinical staff are either employees or working under contract to billing practitioner whom Medicare directly pays for CCM under "General" supervision; not the usual "Direct" supervision

Resources

Updated: 12.17.2025

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