Chronic care management requirements checklist

Chronic care management requirements begin with the patient and the service, before the billing code. CMS expects both the prerequisites for starting CCM and the ongoing scope of care; a monthly timer cannot replace either.

Use this checklist to assign responsibility before enrollment and to decide what your billing team needs at month end. The steps distinguish CMS requirements from practical recordkeeping suggestions, so your team can build a workable process without treating a template as a payment determination.

Chronic care management requirements before enrollment

CMS defines eligible patients as having two or more chronic conditions expected to last at least 12 months or until death, with significant risk of death, acute exacerbation or decompensation, or functional decline. Two diagnosis labels alone do not explain that risk. The billing practitioner should be able to connect the chronic conditions to the need for longitudinal management.

Physicians, nurse practitioners, physician assistants, clinical nurse specialists and certified nurse-midwives may bill CCM within the applicable rules. Clinical staff may furnish qualifying services under the billing practitioner’s direction and general supervision. Your practice remains responsible for the service when another organization assists with operations.

Decide who owns the eligibility review, who discusses the service with the patient and who resolves a disputed billing month. These are practical assignments, not new Medicare job titles. Put the responsibility beside the requirement so an incomplete step has a clear owner.

Step	Who does it	What CMS requires	Record kept
1. Eligibility	Billing practitioner	Multiple long-term conditions and significant risk	Conditions, expected duration and clinical assessment
2. Initiating visit	Billing practitioner	Qualifying visit for new patients or those not seen within the previous year; CCM discussed	Encounter date, service and discussion
3. Consent	Practice consent workflow	Required information explained and acceptance or refusal documented	Dated consent note and practitioner identity
4. Care information	Practice care team	Structured electronic information and comprehensive electronic care plan	Current clinical information, plan and copy-sharing record
5. Access and coordination	Billing practitioner and care team	Urgent access, continuity, communication and relevant coordination	Instructions, team assignment and coordination notes
6. Monthly work	Eligible practitioner or clinical staff	Service and time supporting the selected code	Activity log and code-specific review
7. Claim handoff	Practice billing team	No duplicate time or prohibited overlapping billing	Reconciled month and resolved exceptions

CMS chronic care management requirements: start the service

Step 1: Confirm eligibility and clinical need

Review the current conditions, expected duration and risks with the practitioner. A diagnosis report can identify candidates, but it should lead to a clinical review rather than automatic enrollment. Keep the reason for the referral visible to the team developing the care plan.

Do not use a closed list of diagnoses as the only screen. CMS gives examples of chronic conditions, but eligibility follows the full definition. A patient may have diagnoses on that example list and still require an individualized assessment of risk and need.

Step 2: Resolve the initiating-visit requirement

An initiating visit is required for a new patient or one the billing practitioner has not seen within the previous year. CMS permits a comprehensive face-to-face E/M visit, an annual wellness visit or an initial preventive physical examination. The practitioner must discuss CCM during the encounter for it to count.

The initiating visit is separate from CCM and may be billed separately. Check both the date and the documented discussion; a recent appointment does not establish that the service was introduced. If a visit is needed, complete that requirement before starting the monthly workflow.

Step 3: Obtain and record informed consent

CMS permits written or verbal consent. Explain that CCM is available, possible cost sharing, that only one practitioner can provide and bill it in a calendar month, and the right to stop effective at the end of the month. Document the explanation and whether the patient accepted or declined.

Consent and the initiating visit are separate requirements, and consent need not occur during that visit. CMS generally requires consent once unless the patient changes CCM practitioners. The CCM consent guide explains the information a form or verbal-consent note should capture.

Set up the care plan and access arrangements

Step 4: Establish electronic information and the care plan

CMS requires structured recording of demographics, problems, medications and medication allergies in acceptable certified EHR technology. This requirement is about the practice’s patient information. It does not mean that any particular outside company is integrated with the practice’s EHR.

The comprehensive care plan is electronic and patient-centered, based on physical, mental, cognitive, psychosocial, functional and environmental assessment plus resources and supports. Create, revise and monitor it according to the service descriptor. Make it available promptly within and outside the practice, and provide a copy to the patient or caregiver as required.

A practical plan identifies the problems being managed, goals, planned interventions, medication issues and the people responsible for follow-up. The record should show what is current rather than simply preserve the original enrollment assessment. A care-plan document with no connection to the work performed makes the monthly story harder to follow.

Step 5: Arrange access, continuity and coordination

CMS requires access to physicians, other qualified practitioners or clinical staff for urgent needs 24 hours a day, 7 days a week. It also requires continuity with a chosen care team member and enhanced communication, including telephone and asynchronous methods. These are service requirements the billing practice must arrange, not an assumption about a partner’s hours.

• Give the patient clear instructions for contacting the responsible care team.
• Identify the team member involved in routine continuity and follow-up.
• Define how messages and unresolved clinical issues reach the practitioner.
• Record coordination with other clinicians and community-based providers when indicated.

The scope includes medical, functional and psychosocial assessment, preventive-service needs, medication review and self-management oversight. It also includes relevant home- and community-based coordination and management of transitions between care settings. CMS expects the scope elements unless a particular element is not medically indicated.

Keep the operational instructions accessible to the people doing the work. If a patient calls with an issue, staff should know who receives it and how the response is documented. That design helps the practice deliver the required service instead of discovering missing arrangements during claim review.

Document the month before selecting its code

Step 6: Match activities and time to the service

CCM codes distinguish who performs the work and the applicable monthly time. For example, 99490 describes the first 20 minutes of clinical-staff CCM directed by a physician or other qualified professional in a calendar month, and 99439 describes additional 20-minute increments. Other CCM pathways have different requirements.

Record the person performing the activity, date, purpose, work completed and duration. Those fields are practical evidence suggestions; they do not replace the service descriptor or applicable supervision rules. A total with no explanation of the work is less useful than a record that lets the practitioner and biller understand it.

Do not count the same time toward another billed service. Resolve any overlapping record before choosing the code, and do not treat additional time alone as evidence that complex CCM requirements were met. The CCM documentation guide provides a more detailed review of the monthly record.

An attempted contact may explain why follow-up remains open, but your team must assess the actual qualifying work before counting time. Do not automatically convert call attempts, calendar reminders or software activity into clinical-staff service time. When an activity is uncertain, have the practitioner and billing lead resolve it under the applicable instructions.

Hand the billing team a resolved record

Step 7: Review exceptions before submitting the claim

CMS bases CCM on a calendar-month service period. A claim may be submitted after the service requirements are met, but your team must also make sure the same month will not generate duplicate or incompatible charges. A clean handoff states the period, practitioner, selected code and evidence supporting it.

Keep unresolved items separate from the ready-to-bill queue. Examples include missing consent, uncertain initiating-visit history, an incomplete care plan or time that appears in another service log. Sending the record back with a specific question is more useful than asking someone to make the note longer.

For an outside-service arrangement, agree how the practice receives records and how questions return to the person who can resolve them. Review the services agreement alongside the workflow, including supervision and the responsibilities retained by the practitioner. The billing decision still belongs to the practice.

Put the requirements into your practice workflow

Practices considering outside support can review chronic care management for the service model. Your team refers; we handle enrollment, outreach and documentation. You bill monthly under your license.

Which team members’ time counts toward each code is set in your services agreement. Use the checklist to assign the practitioner decisions, the operational handoffs and the final claim review before the program starts.

Key takeaways

• Eligibility includes long-term conditions and significant clinical risk.
• The initiating visit and informed consent are separate requirements.
• A comprehensive electronic care plan is part of the service.
• Access, continuity and coordination must be arranged alongside monthly work.
• The practice bills only when the selected service is supported.

Frequently asked questions about chronic care management requirements

Are two diagnosis codes enough to start CCM?

No. The conditions must meet the duration and risk criteria, and the practice must satisfy the other service requirements.

Does every existing patient need a new initiating visit?

CMS requires the visit for new patients and patients the billing practitioner has not seen within the previous year. Check the patient’s encounter history and whether CCM was discussed.

Must CCM consent happen at the initiating visit?

No. CMS treats consent and the initiating visit as separate requirements, so the consent discussion may occur separately.

Does the care plan have to be electronic?

CMS requires an electronic comprehensive care plan. The practice must also meet the structured patient-information requirements.

Does reaching 20 minutes automatically support 99490?

No. The service must meet eligibility, consent, care-plan and other applicable requirements as well as the time threshold.

Who submits the CCM claim when a practice uses outside support?

The eligible billing practitioner or practice submits the claim. Outside assistance does not transfer the practice’s billing responsibility.

For physician practices evaluating Companian, Medicare Part B chronic care management codes 99490 and 99439 require supported patient eligibility, consent, care planning and monthly services. Your team refers; we handle enrollment, outreach and documentation. You bill monthly under your license.

Read more: CCM consent requirements · CCM documentation

Disclosures

This guide summarizes CMS rules for practices nationwide and is not legal or billing advice.