Chronic Care Management (CCM) servicesCoordinated care,
month after month.
For patients with two or more chronic conditions: care plans, medication management, and steady human contact — with documentation built in.
The mechanics of good chronic care.
CCM works when the plan is real, the contact is consistent, and the documentation is clean. We handle the operational layer so your team can focus on the clinical one.
Personalized care plans
Care plans built around each patient’s conditions, goals, and barriers — updated as their picture changes.
Medication management
Reconciliation, adherence tracking, and side-effect monitoring across the full medication list.
Care team coordination
A shared workspace that connects providers, care managers, patients, and caregivers around one plan.
Progress tracking
Outcomes captured over time, with the reports your team needs for quality programs and audits.
From enrollment to reimbursement.
Identify eligible patients
Patients with two or more chronic conditions are surfaced from your panel for enrollment review.
Build the care plan
A comprehensive plan is built with the patient — covering medications, goals, and check-in cadence.
Coordinate the month
Our care managers log time on calls, education, coordination, and medication checks across the month.
Bill & report
Time and activities map to 99490, 99439, and complex CCM codes — handled by our billing team.
Everything a CCM month actually requires.
CMS rules are specific. We build the program around the rules, not the other way around.
Comprehensive care plan
Built and maintained for each enrolled patient.
20+ min of care manager time
Each calendar month, logged and audit-ready.
Medication reconciliation
Each plan visit and care-plan refresh.
Compliance documentation
Time logs, consent, and reporting kept in order.
Healthier panels, steadier practices.
CCM is one of the most reliable ways to improve outcomes on your sickest patients — and it adds a durable monthly revenue stream while doing it.
- Better outcomes on multi-condition patients
- Reduced ED visits and readmissions
- Higher patient satisfaction and trust
- More face-time saved for in-person visits
- Sustainable monthly revenue stream
- Streamlined care team coordination
The billable CCM building blocks
99490
20+ min care manager time
99439
Each additional 20 min
99487
Complex CCM, 60 min
99489
Complex CCM, +30 min
Built around what your practice already runs.
The EHR you already use
Monitoring data belongs in the chart your clinicians already open, not in a second portal. These connections are built and maintained in-house, and the list is not closed.
In development: Athenahealth, Epic, AdvancedMD.
The specialty you practice in
What is worth monitoring, and what should trigger a call, differs by panel. Each specialty page names the measures, the escalation question, and the codes that commonly apply.
CCM questions, answered plainly.
What CPT codes are used for chronic care management in 2026?
The core CCM codes are 99490 (first 20 minutes), 99439 (additional 20 minutes), 99491 (physician time 30 minutes), 99437 (physician time additional 30), 99487 (complex ccm, first 60 minutes), 99489 (complex ccm, additional 30 minutes), alongside 99491 and 99437 for physician or QHP time and the complex-CCM codes 99487 and 99489. The code structure is unchanged for 2026; national average reimbursement for the core codes runs roughly $51 to $66 — verify current locality rates against the CMS Physician Fee Schedule lookup.
Which patients qualify for CCM?
Medicare patients with two or more chronic conditions expected to last at least 12 months (or until death) that place the patient at significant risk of death, acute exacerbation, or functional decline. Common qualifying combinations include hypertension with diabetes, COPD, heart failure, or chronic kidney disease.
Can CCM and RPM be billed for the same patient in the same month?
Yes. CCM and RPM are complementary and separately billable in the same month as long as the time for each is documented separately and no minute is double-counted. Many practices run both programs for their highest-risk patients.
How does APCM affect CCM billing?
Advanced Primary Care Management (G0556, G0557, G0558) is a monthly bundle without minute tracking; a practitioner who bills APCM for a patient cannot also bill CCM, PCM, or TCM for that patient in the same month. RPM remains separately billable alongside APCM. Which model pays better depends on your patient mix — Neuvora helps practices model both.
What does Neuvora actually do in a CCM program?
That depends on the model you choose. With full-service CCM, Neuvora's care team handles the monthly touchpoints — care-plan management, medication reconciliation support, coordination between providers, and documentation of every minute — under your practice's supervision. Alternatively, your own staff runs the program inside Neuvora's platform with the same tooling. Either way, billing is handled end to end through EHR integrations including Tebra, PrognoCIS, and eClinicalWorks.
Take the operational layer off your plate.
A short scoping call is the fastest way to see how CCM fits your panel.