CCM in 2025: Billing Codes and Workflows for Practices and Small Hospitals

Chronic Care Management (CCM) remains one of the most reliable ways for practices and small hospitals to fund longitudinal, team‑based support for patients with multiple chronic conditions. In 2025, the fundamentals haven't changed: success is mostly about clean eligibility, reliable time capture, and defensible documentation.

Core codes to know (confirm payer rules)

99490: 20 minutes of clinical staff CCM in a calendar month, under physician/other QHP direction.
99439: Each additional 20 minutes of clinical staff CCM, same month (add‑on).
99491: 60 minutes of CCM personally provided by physician/other QHP.
99437: Each additional 30 minutes for 99491 (add‑on).
99487: Complex CCM: 60 minutes of clinical staff time with moderate-to-high complexity care planning.
99489: Each additional 30 minutes for 99487 (add‑on).
PCM (99424–99427): Principal Care Management for a single high‑risk condition (QHP‑provided vs clinical staff).

Tip: For small hospitals with provider‑based clinics, confirm whether the clinic is billing facility vs non‑facility and align documentation language accordingly.

Eligibility and enrollment (fast, clean, repeatable)

Two+ chronic conditions expected to last at least 12 months with significant risk—confirm once, re‑affirm annually.
Obtain informed consent (verbal or written per payer), note how to withdraw.
Document a comprehensive, shareable care plan accessible to the patient and the team.

Time capture that actually works

Track time as you work, not retrospectively.
Attribute minutes to the correct month and code family (CCM vs PCM).
Separate clinical staff vs QHP‑provided time (e.g., 99490 vs 99491).
Use standard snippets for common interventions (med reconciliation, SNF calls, home services coordination) to keep notes consistent.

Staffing models for small teams

Medical assistant or LPN as CCM coordinator, escalates to RN for complex needs.
One RN per 150–200 active CCM patients (tune to your panel complexity).
For small hospitals, centralize across clinics to reduce idle time and improve coverage.

Facility nuances (small hospitals)

Define a clear cost center and routing rules for CCM activities performed by outpatient departments vs clinics.
Align the care plan template with hospital care management notes to avoid duplicate work.

Documentation: minimum viable note

Minute log with date/time blocks.
Risk & goals refreshed quarterly.
Interventions tied to specific goals/barriers.
Care transitions (ED, inpatient, SNF) flagged and summarized.

Quality signals to watch monthly

% patients with documented consent and care plan.
Minutes distribution: how many patients cross 20/40/60 minutes.
30‑day readmissions and ED utilization for CCM enrollees vs baseline.
Open tasks >14 days (care gaps stalling time capture).

Launch checklist (30 days)

[ ] Choose code set (CCM only vs CCM+PCM).
[ ] Finalize templates for consent, care plan, minute log.
[ ] Train MA/LPN/RN on what counts toward minutes.
[ ] Build weekly huddle with escalation rules.
[ ] Start with 50–75 patients; scale to 200+ as workflows stabilize.

Core codes to know (confirm payer rules)

Eligibility and enrollment (fast, clean, repeatable)

Time capture that actually works

Staffing models for small teams

Facility nuances (small hospitals)

Documentation: minimum viable note

Quality signals to watch monthly

Launch checklist (30 days)

Related reading

Related reading

G0511, Explained: A Practical Guide for RHCs & FQHCs

CCM vs. RPM Minutes: How to Track Separately and Stay Audit‑Ready

What CPOM Means for Outsourced Care-Management

Core codes to know (confirm payer rules)

Eligibility and enrollment (fast, clean, repeatable)

Time capture that actually works

Staffing models for small teams

Facility nuances (small hospitals)

Documentation: minimum viable note

Quality signals to watch monthly

Launch checklist (30 days)

Related reading