Chronic Care Management for Complex Conditions

Medicare covers chronic care management (CCM), which is managing a patient’s multiple (2 or more) chronic conditions expected to last at least 12 months, or until their death. Chronic conditions place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline. CCM is a critical primary care service that contributes to better patient health and care. We pay for CCM services provided to patients with multiple chronic conditions under the Physician Fee Schedule (PFS).

We cover CCM and other management services for some patients with complex conditions. 

Who’s Eligible?

We cover CCM for chronic conditions, including, but not limited to:

• Alzheimer’s disease and related dementia
• Arthritis (osteoarthritis and rheumatoid arthritis)
• Asthma
• Atrial fibrillation
• Autism spectrum disorders
• Cancer
• Cardiovascular disease
• Chronic obstructive pulmonary disease (COPD)
• Depression
• Diabetes
• Glaucoma
• HIV and AIDS
• Hypertension (high blood pressure)
• Substance use disorders

We also cover CCM for some patients with complex conditions, requiring moderate or high complexity medical decision making, including, but not limited to:

• Infection-associated chronic conditions and illnesses (IACCI), including those with:
  • Clearly identifiable infectious triggers, like Lyme disease
  • Difficult to identify infectious triggers, like myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS)
• Conditions with potentially challenging, clinically challenging, or ambiguous diagnoses
• Conditions with limited biomarkers for evaluation

What’s My Role?

Develop a comprehensive care plan for optimal, reasonable, and necessary care. Due to diagnostic uncertainty, the Centers for Medicare & Medicaid Services (CMS) doesn’t define these plans.

To develop a care plan, you may:

• Conduct a thorough physical exam
• Do a broad and systematic differential diagnosis
• Evaluate prior laboratory evaluation and treatment history

A comprehensive care plan focusing on managing chronic conditions may include: 

• Problem list
• Expected outcome and prognosis
• Measurable treatment goals
• Revision and monitoring (per code descriptors), when necessary
• Cognitive and functional assessment
• Symptom management
• Planned interventions
• Medical management
• Environmental evaluation
• Caregiver assessment
• Interaction and coordination with outside resources and practitioners
• Periodic review

Due to a patient’s complex needs, your care plan may focus on:

• Ongoing evaluation of medical and psychosocial needs
• Coordination with specialty care providers as part of an interdisciplinary team
• Trust building aligned around shared treatment goals
• Encouraging a focus on improved quality of life

How Do I Get Started?

Before CCM services can start, we require an initiating visit for new patients or patients who haven’t been seen within the previous 1 year. Conduct the initiating visit during the comprehensive face-to-face evaluation and management (E/M) visit, annual wellness visit (AWV), or initial preventive physical exam (IPPE).

How Do I Bill?

View Chronic Care Management (PDF) for information on how to bill.

A face-to-face initiating visit isn’t part of CCM and can be separately billed. If you personally provide extensive assessment and care planning outside the usual effort described by the initiating visit and CCM codes, you may also bill HCPCS code G0506 once, as part of an initiating visit.