What Auditors Are Looking For
- Time ledger integrity. CCM requires a minimum of 20 minutes of non-face-to-face clinical staff time per calendar month, directed by a qualified provider. Auditors look for rounded entries, time credited to administrative rather than clinical staff, and time that overlaps with other billed services.
- Care plan documentation. A comprehensive, patient-specific electronic care plan is required. Generic templates that do not reflect the patient’s individual chronic conditions, current medications, and care coordination activity will not hold up. Documentation that the care plan was shared with the patient is also required.
- Patient eligibility and consent. Patients must carry two or more chronic conditions expected to last at least 12 months and place the patient at significant risk. Practices must document clinical justification for eligibility and proof of informed consent before services begin.
The Audit Is a Pressure Test, Not a Reason to Stop
What the Forthcoming Whitepaper Will Cover
- Financial: The reimbursement structure of CCM in detail, including the logic behind the 99439 add-on code and what practices consistently leave on the table by not understanding how time-based billing works under the current Physician Fee Schedule.
- Compliance: What we call substantial exposure: the gap between what practices believe their documentation supports and what an auditor will actually accept. Pre-bill claim logic, time ledger standards, and the care plan evidence requirements that distinguish compliant programs from ones that will not survive scrutiny.
- Operations: What scalable CCM infrastructure looks like, including the difference between Self-Managed and Managed Clinical models and how each affects compliance posture and program sustainability.
- Clinical: What continuous engagement between visits actually produces. Earlier identification of complications before they escalate, reduced fragmentation across the care team, and documented physiologic improvement in patient populations that are actively monitored.
Next Steps
Sources and Further Reading
- OIG Work Plan Project OAS-26-09-007: Audit of Medicare Payments for Chronic Care Management Services at Risk of Noncompliance. Announced March 16, 2026. Active.
- Centers for Medicare and Medicaid Services: CMS Physician Fee Schedule: Chronic Care Management Services.
- CMS Medicare Learning Network: Chronic Care Management Services MLN Booklet, updated 2024.
- Office of Inspector General: OIG Semiannual Report to Congress. U.S. Department of Health and Human Services.