Chronic Care Management (CCM) is a Medicare Part B service that pays eligible practitioners for coordinating ongoing care for patients with two or more qualifying chronic conditions, much of it between office visits.
CCM compliance is not a final billing check. Every claim begins with patient selection, before the timer starts, and continues through eligibility, consent, care planning, monthly delivery, documentation and billing. [1]
In March 2026, the HHS Office of Inspector General added an audit of Medicare CCM payments to its active Work Plan. The audit is examining whether services met Medicare’s requirement that a patient have two or more qualifying chronic conditions. Findings are expected in FY2028. [2]
That focus matters. Recording enough time cannot cure a weak eligibility decision. The evidence must support the claim from the point at which the patient is selected through the point at which the service is billed.
A CCM claim is only as defensible as the care pathway behind it.
The defensible CCM pathway at a glance
Patient qualification → documented consent → individualized electronic care plan → visible monthly activity → supervision and escalation → overlap checks → pre-bill review
Why Medicare CCM eligibility now matters
Medicare CCM eligibility requirements are clinical, not simply a count of diagnosis codes. The patient must have at least two chronic conditions expected to last at least 12 months, or until death, and those conditions must place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline. [1]
Diabetes and hypertension may satisfy the diagnosis count, but that alone does not establish complete eligibility. A defensible note also connects the conditions to their expected duration, significant clinical risk and the need for ongoing coordinated care.
Facility status also belongs in this check. A separate CPT 99490 claim generally should not be made when a facility’s Medicare payment already includes care management. A covered Part A skilled nursing facility stay is a common tripwire because consolidated billing includes most services, subject to limited exceptions.
Residence alone is not the complete test. Teams should verify the covered-stay, service and payment facts. [3]
CMS improper-payment data: a warning signal, not a fraud rate
The Centers for Medicare & Medicaid Services’ 2025 supplemental improper-payment report covers claims submitted from July 1, 2023, through June 30, 2024.
For CPT 99490, CMS estimated a 65.2% improper-payment rate, representing approximately $205.4 million in projected improper payments. Insufficient documentation accounted for 87.7% of the projected improper payments associated with the code. [4]
The estimate was based on 68 reviewed claims and 68 claim lines, with a 95% confidence interval of 53.4% to 77.0%. That wide statistical range matters. The finding is a serious warning signal, not a universal CCM failure rate. [4]
An improper payment is not the same as fraud. CMS uses the term for payments made incorrectly or without enough information to determine their accuracy. It signals documentation or payment exposure, not necessarily deliberate wrongdoing. [5]
Enforcement can nevertheless extend beyond repayment. In 2024, the Department of Justice announced a settlement of approximately $14.9 million with Bluestone entities over alleged False Claims Act violations involving chronic disease management services, including CPT 99490.
There was no determination of liability, but the case shows how repeated billing weaknesses can escalate. [6]
Seven controls for stronger Chronic Care Management compliance
1. Confirm CCM eligibility before enrollment
Confirm the two-or-more-condition test, expected duration and clinical risk before enrollment. Record the reasoning rather than relying only on the problem list.
Confirm whether an initiating visit is required for a new patient or a patient who has not been seen within the previous year. Check facility and covered-stay status, and repeat the review whenever the patient’s circumstances change. [1]
2. Document informed consent
Before the service begins, explain CCM, likely cost-sharing, the patient’s right to stop and the rule that only one practitioner can bill CCM for the patient in a calendar month.
Record the consent in the medical record in a form the care team can retrieve easily. [1]
3. Build an individualized comprehensive care plan
The electronic comprehensive care plan should translate diagnoses into patient-specific goals, interventions, medication management and coordination needs.
Give the patient or caregiver a copy, make it available to others involved in the patient’s care and update it as needs change. The workflow should also provide 24/7 access for urgent needs and continuity with a designated member of the care team. [1]
The care plan should function as a living record of the work being performed. If the patient’s condition, medication, goals or interventions change, the plan should change with them.
“Rather than doing a one size fits all, we really look at our patients and tailor which programs would they benefit from.” [9]Dr. Aamir Iqbal, MD, Medical Director, Vivo Care
4. Make CPT 99490 monthly activity visible
For CPT 99490, the record needs at least 20 minutes of qualifying clinical-staff time directed by a physician or other qualified healthcare professional during the calendar month. [1]
Log the staff member, activity, date, duration and result. A monthly total without the underlying activity makes the service harder to review and defend.
For example, a note might record that medication reconciliation identified a discrepancy, the practitioner was notified and follow-up was arranged. Following an emergency visit or hospital discharge, it might show how information was exchanged and care was coordinated.
In each case, the documentation should capture who completed the work, when it occurred, how much time it took and what happened next.
5. Prevent duplicate billing and overlapping service time
Code-level and time-level checks should run before billing. CPT 99490 and practitioner-delivered CCM code 99491 cannot be reported for the same patient in the same month.
For clinical-staff CCM, CPT 99439 add-on billing applies to each additional 20 minutes beyond the first 20 minutes reported under CPT 99490. [1]
CCM and Remote Patient Monitoring may sometimes be billed concurrently when each service independently qualifies, but the same minutes or work cannot support both claims. [1]
Previous OIG reviews have also identified overpayments involving duplicate CCM claims and overlapping care-management services. That history illustrates why these checks need to happen before billing. [7]
Part 4 of this series will examine overlapping care-management services in greater detail.
6. Define CCM supervision and escalation
Clinical staff may furnish qualifying CCM minutes under general supervision, but the billing practitioner remains responsible for the service and provides overall direction and control. [1]
The workflow should state which findings require practitioner review, how quickly they must be escalated and where the practitioner’s response is documented.
Part 3 of this series will explore this accountability in more detail.
7. Complete a CCM pre-bill review
Pre-bill review should test more than the minute threshold.
Confirm eligibility and any required initiating visit, consent, the care plan, access and continuity arrangements, qualifying activity and care transitions, required time, practitioner responsibility, facility status and the absence of conflicting or duplicated services.
Resolve exceptions before submission, not after a denial or audit.
Why CCM compliance controls matter as enrollment grows
Vivo Care chronic care management programs grow two ways. Practices move to Managed Clinical after running the program themselves, and programs that were underperforming get rebuilt. Neither is a technology story. Both come down to how the care navigator team is structured, how patients are engaged, and how the program is set up in its first weeks.
That is also why compliance controls belong inside the workflow rather than in a quarterly review. A program that grows through conversions and rebuilds inherits documentation habits it did not design. The controls have to live in how the care team works day to day, rather than get bolted on at billing.
Qualification prompts, structured consent, care-plan fields, activity logs, escalation routes and pre-bill checks need to be built into the workflow.
Technology does not make a claim compliant by itself. It can, however, make the required evidence easier to capture, review and retrieve consistently.
A nine-question CCM pre-bill check
Before sampling a paid claim, remember that self-review has consequences.
Under the Medicare overpayment rule, an identified overpayment generally must be reported and returned by the later of 60 days after identification or the applicable cost-report deadline.
A timely, good-faith investigation of related overpayments may suspend the deadline for up to 180 days. Organizations should involve their compliance or legal advisers where appropriate. [8]
For a lower-risk starting point, apply these questions during the pre-bill review of an unsubmitted claim:
- Does the record support two or more chronic conditions, their expected duration and the required level of risk?
- Was the patient’s facility and covered-stay status checked?
- Was informed consent documented before billing began?
- Is there a current, individualized electronic comprehensive care plan?
- Can every counted minute be tied to a qualifying activity and an eligible care-team member?
- Does the record show what happened, what changed and what follow-up was required?
- Were escalation rules followed, and is practitioner involvement visible where required?
- Were mutually exclusive codes and duplicated time ruled out?
- Could a reviewer understand the entire month without relying on an after-the-fact explanation?
If any answer is unclear, treat it as a workflow finding.
The goal is not to defend a claim with better prose later. It is to make the underlying care pathway clearer before the claim leaves the organization.
A defensible CCM pathway enables confident growth
A defensible pathway turns Chronic Care Management compliance into infrastructure for expansion while supporting consistent follow-up, clear escalation and coordinated care.
It gives a CCM program the structure to add patients and staff without losing control of eligibility, care delivery or billing evidence.
Part 2 of this series will examine how those controls should develop as enrollment grows.
Download the CCM Monthly Audit Checklist →
Read The 2026 Chronic Care Management Guide for the wider eligibility, coding, documentation and operating context. The guide has been medically reviewed by Dr. Aamir Iqbal, MD, Medical Director, Vivo Care. [10]
If the checklist or the nine questions expose gaps, discuss your workflow with Vivo Care to identify where eligibility, documentation or pre-bill review could be strengthened.
Frequently asked questions
What conditions qualify a patient for Medicare CCM?
Medicare does not publish a closed list of qualifying conditions.
The patient needs at least two chronic conditions expected to last 12 months or until death, with significant risk of death, acute exacerbation or decompensation, or functional decline. The record must support those elements. [1]
Is having two diagnoses enough to establish CCM eligibility?
No. Two diagnoses satisfy only the numerical part of the test.
The record should also support the conditions’ expected duration, clinical risk and why ongoing coordinated care is appropriate. [1]
What are the core CMS requirements for Chronic Care Management?
At a high level, the patient must qualify clinically, complete an initiating visit when required, consent to the service and have an electronic comprehensive care plan.
The program must also provide the required access and continuity of care, meet the relevant time and staffing rules, and prevent duplicate billing. [1]
Does recording 20 minutes automatically make CPT 99490 billable?
No. The minutes must reflect qualifying work by eligible clinical staff under the required direction.
The patient must also meet the other requirements, including eligibility, consent and an electronic comprehensive care plan. [1]
Can CCM and RPM be billed together?
They may sometimes be billed in the same month when each service independently meets its requirements.
However, the same work or minutes cannot be counted toward both CCM and Remote Patient Monitoring, and other code-specific restrictions still apply.
A pre-bill review should test both the code combination and the underlying activity. [1]
What documentation makes a CCM claim defensible?
A defensible record connects the patient’s eligibility, any required initiating visit, consent, electronic care plan, qualifying monthly activity, practitioner oversight and billing decision.
A reviewer should be able to follow the entire pathway without relying on an explanation created after the claim was submitted.
References
- Centers for Medicare & Medicaid Services: Chronic Care Management Services. An accessible overview of CCM eligibility, consent, care planning, time, supervision and concurrent billing requirements.
- HHS Office of Inspector General: Audit of Medicare Payments for Chronic Care Management Services at Risk of Noncompliance. The active audit examining whether CCM services met Medicare’s multiple-chronic-condition requirement.
- Centers for Medicare & Medicaid Services: Skilled Nursing Facility Consolidated Billing. An explanation of when services are included in a covered Part A skilled nursing facility stay.
- Centers for Medicare & Medicaid Services: 2025 Medicare Fee-for-Service Supplemental Improper Payment Data. The source of the CPT 99490 improper-payment estimate, documentation findings, sample size and confidence interval.
- Centers for Medicare & Medicaid Services: Fiscal Year 2025 Improper Payments Fact Sheet. CMS’s explanation of improper payments and why they should not automatically be interpreted as fraud.
- U.S. Department of Justice: Chronic Disease Management Provider to Pay Approximately $14.9 Million to Resolve Alleged False Claims. The DOJ announcement describing the settlement and allegations, with no determination of liability.
- HHS Office of Inspector General: Medicare Continues to Make Overpayments for Chronic Care Management Services. An earlier audit identifying duplicate CCM claims and overlapping care-management services.
- 42 CFR § 401.305: Requirements for Reporting and Returning Overpayments. The federal regulation covering the reporting, investigation and return of identified Medicare overpayments.
- Vivo Care: CMS 2026, Putting Policy into Practice. Public webinar, January 2026. Source of the quotation from Dr. Aamir Iqbal, MD.
- Vivo Care: The 2026 Chronic Care Management Guide. Medically reviewed by Dr. Aamir Iqbal, MD, Medical Director, Vivo Care.
This article is provided for educational purposes and does not constitute legal, medical or billing advice. Organizations should consult current CMS guidance, their Medicare Administrative Contractor and appropriately qualified advisers before making billing decisions.