No time for monthly calls?
Chronic care management for primary care practices
Your practitioners already run the visits and write the care plans. We add the monthly calls and minutes.
- No new hires. We run outreach, consent and monthly calls.
- One file a month. Nothing is billed until you approve it.
- $0 upfront. Works with your EHR, live in about a week.
$66.13* per patient, every month*Primary care CCM, CPT 99490 (2026 national rate)
Get your CCM Plan
Works nationwide
Practices nationwide
You bill under your own NPI
Same Care Advocate every month
RNs, NPs, LCSWs and care companions
Monthly file approved by your team
No new hires needed
One Care AdvocateSame person, every month
Your NPI, your claimYou bill Medicare directly
Monthly billing fileYour team approves it
No upfront cost to the practice. Your team refers, we handle enrollment, outreach and documentation, and you bill Medicare under your own license. We connect with your EHR in about one week, and have worked with eClinicalWorks, Tebra and athenahealth.
Why CCM starts in the primary care office
CMS ties CCM to the practitioner who sees the patient and writes the plan.
Your visits open the door
Patients not seen in the past year need an initiating visit: a comprehensive E/M, annual wellness visit or IPPE. You run all three. For E/M visit add-ons, see our guide to the G2211 add-on code.
Your practitioner writes the plan
CMS MLN909188 asks for an electronic care plan with problems, measurable goals and assessments. Care Advocates work from it; they never change it.
Your panel decides the code
Several chronic conditions, one serious condition or Qualified Medicare Beneficiary status: each points to a different code family, compared below.
Your MAs keep their day
Registered nurses, nurse practitioners, licensed clinical social workers and care companions call remotely by phone and video, so outreach never competes with rooming.
What 250 primary care CCM patients bring in each month
2026 Medicare-allowed amounts, and the diagnosis codes that qualify.
Example panel
$16,533 / month
$198,390 a year · 250 patients × $66.13 (CPT 99490, national)
- CPT 99490 pays $66.13 per patient-month nationally (2026).
- Your locality moves it up or down: $60.71 in Arkansas to $83.76 in Alaska.
- Each extra 20 minutes adds CPT 99439 at $50.44.
| Condition | ICD-10 examples | Program fit |
|---|---|---|
| Hypertension | I10 | CCM with a second condition |
| Type 2 diabetes | E11.9 | CCM with a second condition |
| Hyperlipidemia | E78.5 | CCM with a second condition |
| COPD | J44.9 | CCM with a second condition |
CCM, APCM or PCM: which fits each patient
One program per patient, per practitioner, per month. Conditions, minutes and QMB status decide.
| Patient in your panel | Program to compare | Time rule | 2026 payment, national |
|---|---|---|---|
| Two or more chronic conditions, 20 to 39 minutes of staff time in the month | CCM · 99490 | First 20 minutes of clinical staff time | $66.13 national |
| Same patient, 40 minutes or more | CCM · 99490 + 99439 | 99439 for each further full 20 minutes | $116.57 for 40 minutes, national |
| Two or more conditions, a month your practitioner judges complex | Complex CCM · 99487 | First 60 minutes; 99489 adds each 30 | $144.29 national |
| Two or more conditions, months that may fall short of 20 minutes | APCM · G0557 | No time threshold | $53.78 national |
| Two or more conditions and Qualified Medicare Beneficiary status | APCM · G0558 | No time threshold | $117.24 national |
| One serious, high-risk condition expected to last at least 3 months | PCM · 99426 | At least 30 minutes | $67.80 national |
Three CMS rules for APCM
- It is billed monthly by the practitioner responsible for all of the patient’s primary care.
- It cannot be reported with CCM or TCM in the same month.
- Your practice provides 24/7 access and seven-day discharge follow-up, as clinically appropriate.
If those already run panel-wide, compare APCM for QMB patients and months under 20 minutes. If not, start with CCM. Companian sets up APCM practice by practice; see APCM vs CCM.
How chronic care management for primary care practices runs
Your staff does three things. Our care team carries the rest of the month.
You pick the patients
Share a list through EHR access or a short referral form. Your practitioners leave off anyone they would not refer.
You approve outreach
Once you approve a patient, the Care Advocate calls, explains the program and Part B cost-sharing, and documents verbal consent.
One Care Advocate
One person asks care-plan questions and routes anything new to your clinicians. Gloria, our AI, drafts notes and pre-visit summaries.
Month-end file
Your billing team approves each patient’s program, month, minutes, activities and consent date. Under-threshold months don’t support timed codes.
Building the first patient list from your panel
Four checks before outreach, each tied to a CMS rule.
Two or more chronic conditions
Lasting 12 months or more with significant risk, such as hypertension, diabetes or heart failure. Your practitioner decides; see the eligible conditions guide.
A visit within the past year
Raise CCM at the annual wellness visit. 2026 national amounts: $174.35 initial (G0438), $137.61 subsequent (G0439).
No other CCM biller
One practitioner bills CCM per patient per month. If a cardiologist or nephrologist already does, agree who bills; the specialist may bill PCM instead.
QMB status and blocked months
QMB status decides G0558 under APCM. Skip months billed for home health or hospice supervision (G0181, G0182) or monthly ESRD services (90951 to 90970).
CCM alongside TCM, remote monitoring and CHI
What CMS allows with CCM or APCM in the same month.
| Service in the same month | With CCM | With APCM, same practitioner |
|---|---|---|
| Transitional care management (99495, 99496) | Allowed during the 30-day TCM period, with no minute counted twice | Not billed together |
| Remote physiologic or therapeutic monitoring | Either RPM or RTM, not both | Confirm with your billing team |
| Community health integration (G0019, G0022) | Allowed when time and effort are counted once | Allowed when time and effort are counted once |
| Prolonged E/M services | Not with complex CCM (99487, 99489) | — |
Your practitioner keeps the TCM face-to-face visit: within 14 days for 99495, 7 days for 99496. CHI follows an initiating visit when transport, food or housing gets in the way of treatment; see community health integration.
Questions primary care practices ask
Can a nurse practitioner or PA be the billing practitioner?
Yes. CMS lists physicians (MD or DO), nurse practitioners, physician assistants, clinical nurse specialists and certified nurse midwives as practitioners who can bill CCM.
Who supervises the Care Advocates?
The billing practitioner, under general supervision: the service runs under their overall direction and control. Your services agreement sets out how; confirm it with your counsel.
Do patients have to consent again every year?
No. CCM consent is documented once, verbally or in writing, before the first claim. It holds until the patient stops. Companian records the consent date in each monthly file.
Do we need new software?
No. Our chronic care management for primary care practices works from EHR access you grant or a short referral form. Documentation comes back in the monthly file.
What does Companian charge the practice?
Your practice bills Medicare and receives the payment. Companian’s fee is walked through on the intro call; see what CCM costs for the patient side.
Rates & disclosures
National amounts are 2026 Medicare Physician Fee Schedule non-facility payments at the non-QP conversion factor of $33.4009, computed from CMS RVUs. Your amount depends on your Medicare payment locality; see it in the CCM/PCM revenue calculator. Actual payment depends on participation status, place of service and cost-sharing.
Companian supplies Care Advocates and documentation to physician practices nationwide. Companian is not a medical practice and does not bill Medicare. The billing practitioner keeps the care plan, every clinical decision and the claim. Patients pay the usual Medicare Part B deductible and coinsurance for these services unless other coverage pays it.
Bring chronic care management to your primary care practice
Fifteen minutes on your panel and which program fits. No patient information needed.